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COPYRIGHT DEPOSIT. 



MEDICAL 
GYNECOLOGY 



BY 

SAMUEL WYLLIS BANDLER, M.D. 

ii 

FELLOW OF THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNE- 
COLOGISTS ; ADJUNCT PROFESSOR OF DISEASES OF WOMEN, NEW YORK POST- 
GRADUATE MEDICAL SCHOOL AND HOSPITAL ; ASSOCIATE ATTENDING 
GYNECOLOGIST TO THE BETH ISRAEL HOSPITAL, NEW YORK CITY 



WITH ORIGINAL ILLUSTRATIONS 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1908 



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LIBRARY of CONGRESS, 
two Copies Receives 

JUL 9^ 1908 
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GLASS A XXc, Mo, 
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COP Y Q, 

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Copyright, 1908, by W. B. Saunders Company 



PRINTED IN AMERICA 



PRESS OF 
B. SAUNDERS COMPANY 
PHILADELPHIA 



DEDICATED TO 

Hermann &t. 3iotm WolbU $$. 2D M 

PROFESSOR OF DISEASES OF WOMEN, N. Y. POST-GRADUATE MEDICAL SCHOOL ANL 

HOSPITAL 



IN ADMIRATION OF HIS SURGICAL ATTAINMENTS 

AND AS A TOKEN OF MY SINCERE 

REGARD AND ESTEEM 



PREFACE 



This book has been written as a result of frequent inquiries 
for a work dealing with the non-operative side of gynecology. 
It represents, with elaborations, a grouping and rearrangement 
of my clinical lectures. The various topics have been viewed 
from the standpoints of the symptoms, the disease, the bimanual 
and microscopic findings, and the general physical and nervous 
state. 

The knowledge .gained by studying the diseases of women from 
these different points of view gives a more distinct mental picture 
and furnishes logical coordinated conclusions. The resulting 
repetition and reiteration emphasize important points and make 
each section fairly complete in itself, thus diminishing as much 
as possible the necessity of referring to other sections, except 
for more complete elucidation. 

Operative procedures have been viewed as a last resort in those 
numerous conditions where medical means can accomplish so 
much. In no field of medicine is conservative treatment of greater 
value, but, combined with this, there is needed a knowledge of 
the relation of normal and pathologic genital functions to the 
general physical and psychic health of woman. I have endeavored 
to show the relation which pelvic abnormalities really bear to the 
physical and mental state of the female, in order that we may deal 
intelligently with gynecologic diseases and not confine our diagnosis 
and therapeutic methods to the pelvis. 

The life and make-up of woman are such that, aside from the 
diseases and injuries to which she is liable, physiologic processes, 
heredity, predisposition, mental perturbation, the emotions, marital 
relations, etc., have an important bearing, and, therefore, the 
physician who enters into a study of these factors becomes a far 
better judge of the meaning of symptoms. 



I 2 PREFACE 

I have consulted particularly the writings of Kisch (puberty), 
Joseph (syphilis and gonorrhea), Bumm, Wertheim and Finger 
(gonorrhea), Oskar Frankl (electricity and hydrotherapy). 
To the teachings and writings of Winter must be credited much 
of the advance in matters relating to diagnosis and to carcinoma. 
I gladly record my especial obligation to him for much that has 
aided me these past twelve years and, consequently, for much 
that appears in these pages. 

The chapter on Constipation, written by my friend, Dr. Geo. 
Mannheimer, is in complete harmony with the views expressed in 
other sections, and the value of its teachings must be self-evident. 
I am indebted to Prof. H. T. Brooks, of the Post-Graduate Medical 
School, for valuable opinions and information which were given 
to me while writing the section on Gonorrhea. Dr. I. Strauss 
revised the pages on bacteriologic methods. I am indebted 
to Dr. I. Strauss and to Dr. S. Philip Goodhart for suggestions 
in the section on Associated Nervous Conditions. Dr. Leopold 
Jaches, of the department of photography, Cornell Medical 
School, has been of invaluable aid to me in photographing in- 
struments, apparatus and therapeutic procedures on the patient. 
Mr. K. K. Bosse has made the drawings and illustrations in his 
well-known accurate and artistic manner. I wish to express my 
thanks to the publishers, and particularly to the vice-president, 
Mr. R. W. Greene, for hearty support and assistance in the many 
details connected with the publication of this book. 
New York City, June, 1908. 



CONTENTS 



PAGE 

Gynecologic Examination i y 

History Taking 17 

Examination of the Abdomen , 19 

Inspection and Palpation 21 

Bacteriologic Methods 42 

Methods Employed in Medical Treatment 48 

Urethra . 48 

Bladder 49 

Glands of the Vulva and Urethra 51 

Vagina 52 

Intrauterine Therapy 64 

Pessaries 89 

Pressure Therapy for Resorption and Stretching 98 

Counter-irritation 100 

Bimanual Massage (Vagino-abdominal) in Chronic Conditions 101 

Abdominal Massage 103 

Abdominal Supports 108 

Production of Pelvic Hyperemia and Anemia 109 

Electricity 115 

Influence of Cool and Cold Water Applied to the Body 119 

The Action of Warm Baths 121 

The Nauheim Bath 122 

Amenorrhea 133 

Treatment 148 

Dysmenorrhea 151 

Treatment 162 

Uterine Bleedings 168 

Diagnosis 180 

Treatment 181 

Leukorrhea 195 

Treatment 201 

Pruritus Vulvae 210 

Treatment 214 

Pain 219 

Vaginismus 219 

Dyspareunia 220 

Coccygodynia 221 

Significance of Pelvic Pain 221 

Treatment of Pelvic Pain 236 

Sterility 241 

Causes 242 

Treatment 250 

Frequency of Micturition; Dysuria 258 

Causes 258 

Diagnosis 266 

Symptoms of Tubercular Cystitis 267 

Treatment of Cystitis 269 

Associated Nervous Conditions in Gynecology 275 

Puberty 274 

Nervous Symptoms at Puberty 276 

13 



14 CONTENTS 

PAGE 

Nervous Symptoms in Chlorosis 281 

Nervous Symptoms during Menstruation. 282 

Onanism as a Cause of Nervous Symptoms 283 

Nervous Annoyances in Pregnancy 286 

The Relation of Ptoses to Neurasthenic Symptoms 287 

Diminished Excretion of Urea 289 

Hysteria 289 

Neurasthenia 291 

Reflex Neuroses 293 

Aberrant Basedow's Disease 299 

The Climacterium 300 

The Hygiene of Puberty 309 

Treatment of Chlorosis 312 

Treatment of Nervous Conditions 314 

Constipation 322 

Etiology 324 

Pathology and Pathogenesis 327 

Symptomatology 329 

Diagnosis 331 

Prognosis. 334 

Prophylaxis 334 

Treatment 336 

Gonorrhea in Children 364 

Gonorrhea in Adults 371 

Urethritis 371 

Gonorrheal Cystitis 380 

Gonorrheal Vulvitis 385 

Bartholinitis 386 

Gonorrhea of the Anus and Rectum 388 

Gonorrheal Vaginitis 389 

Cervico-Uterine Gonorrhea 394 

Gonorrhea of the Tubes, Ovaries, and Peritoneum. 405 

Characteristics of Gonorrhea 409 

Gonorrhea in the Male 416 

Unrecognized Gonorrhea in the Female 417 

Genital Syphilis 429 

Ulcus Molle (Soft Chancre or Chancroid) 436 

Vulvitis 439 

Treatment 442 

Colpitis or Vaginitis 445 

Diagnosis 448 

Treatment 449 

Endocervicitis or Cervical Catarrh 451 

Symptoms 466 

Diagnosis of Erosions of the Cervix 468 

Diagnosis of Endocervicitis 469 

Treatment 471 

Endometritis 476 

Symptoms 490 

Varieties 494 

Sequels - 499 

Treatment 5°° 

Inflammatory Metritis 5°4 

Treatment 5°6 

Pelvic Cellulitis and Parametritis 510 

Treatment of Parametritis 5 J 6 

Pelvic Peritonitis; Perimetritis 519 

Uterine Retrodeviations; Retroversio Flexio 524 

Subinvolution 541 

Malposition of the Uterus and Vagina 552 

Treatment - ' 554 



CONTEXTS 15 

PAGE 

Vaginal Hernias 556 

Pregnancy and Abortion 564 

Myometrial Degeneration, Fibrosis, and Arteriosclerosis 576 

Diagnosis 583 

Treatment 584 

Carcinoma 585 

Carcinoma of Vulva 585 

Carcinoma of Vagina •. 588 

Carcinoma of Portio 588 

Carcinoma of Cervix 593 

Carcinoma of Fundus 594 

Characteristics of Cervico-uterine Carcinoma 595 

Symptoms of Carcinoma of Portio, Cervix, and Uterus 597 

Treatment 600 

Chorioeptthelioma 602 

FlBROMYOMA 6lO 

Inflammation of the Fallopian Tubes 620 

Salpingitis — Salpingo-oophoritis 620 

Hydrosalpinx 625 

Tubo-ovarian Cysts 626 

Pyosalpinx 626 

Tubercular Salpingitis 631 

Ectopic Gestation '. 634 

Diseases of the Ovary 651 

Diagnosis 659 

Index 663 



MEDICAL GYNECOLOGY 



GYNECOLOGIC EXAMINATION 
HISTORY TAKING 
A certain definite order should be followed in taking a gyneco- 
logic history, to obtain information concerning the patient's 
physical condition, but more particularly to learn of those im- 
portant factors which play their role in the pelvis and those general 
states which are so profoundly influenced by normal or pathologic 
pelvic processes. The points which are to be held especially in 
mind in taking a gynecologic history are the cardinal symptoms 
which bring women to the physician for their special care — amen- 
orrhea, dysmenorrhea, menorrhagia, metrorrhagia, leukorrhea, 
pruritus vulvas, pelvic pain and backache, sterility, dysuria or 
frequent micturition, nervous annoyances. 

Age. 

If married, how long ? 

If parous, how many children; when; the last child; number 
living ; cause of death ? 

Pregnancies — nausea; vomiting; effect on health; pain during 
pregnancy ? 

Labors — duration; instrumental; how long in bed; temperature? 

Nursing — how long; duration of amenorrhea, of lactation; in- 
fluence of nursing on general health? 

Abortion — Miscarriage — how many; when; in what months ; date 
of last one ; curetted ? 

Diseases oj Childhood — diphtheria; scarlatina; chorea, etc.? 

Other diseases — typhoid; chlorosis, etc. ? 

Establishment oj menstruation — when; regular; longest interval; 
pain before, during, or after; fluid blood or small clots or 
pieces; amount; duration? 

Pain, from the very first menstruation or developing 
after months or years ? 

Nervous conditions before or on establishment of men- 
struation or before each menstruation? 

Pre-menstrual symptoms; headache; fullness in pelvis; 
backache; fullness of breasts ; palpitation; restlessness? 
2 17 



1 8 MEDICAL GYNECOLOGY 

Marriage — dysmenorrhea better or worse; acquired; alteration in 
character of menstruation; leukorrhea or irritation of bladder 
shortly after marriage ; dyspareunia ? 

Menstruation now — how often; duration; amount; pain before,, 
during, or after; in bed during menstruation; date of last 
menstruation; duration of amenorrhea if acknowledged; 
is pregnancy probable ? 

P re-menstrual symptoms — begin how long before menstruation; 
headache; neuralgia; nausea; flushes; palpitation; ner- 
vousness, restlessness; backache? 

P re-menstrual and menstrual pelvic pain — abdominal; in ovarian 
region; in uterine area ; bladder; back; coccyx; radiating 
to hips ; down thighs ; up to the ribs ; how long since noted ; 
related to labor or abortion ? 

Intermenstrual pain — abdominal; ovarian region; bladder; back; 
coccyx; worse during menstruation; sense of bearing down 
or looseness of pelvic organs ? 

Was there ever an acute onset of pain which confined patient to 
bed ; associated with temperature ; loss of blood ; duration 
of attack ; diagnosis made at that time ? 

Urination — frequent; how often; at night; painful; duration of 
annoyance; ever acute; shortly after marriage ; after labor; 
after abortion; pain in kidney region; pain before, during, 
or after urination ? 

Leukorrhea — duration; white; yellow; thin; mucoid; odor; as- 
sociated with burning or urinary annoyance at onset; date 
of beginning; better; worse? 

Pruritus vuIvce — duration; leukorrhea; alterations in skin; thirst; 
amount of urine passed; weight lost? 

Nervous symptoms — languid ; tired ; mental weariness ; depressed ; 
excitable; irritable; cross; cry easily; palpitation; pho- 
bias; sleepless, because of pain or flow of thought or 
worry ; mental shocks ? 

If menopause — how long; came on slowly or suddenly; bleedings 
increased before ceasing finally; flushes; how often; at 
night; nervous; sleepless; depressed; excitable; irregular 
spotting; leukorrhea; disagreeable discharge? 

Headache ; cough ; palpitation ; appetite ; digestion ; character of 
food; constipation; hemorrhoids; drugs or enemata for 
constipation ? 

Family history with especial reference to tuberculosis, diabetes,, 
and carcinoma ? 

Gain or loss in weight; increase in size of abdomen? 

Careful questions concerning symptoms of syphilis if indicated. 

Operations ; previous treatments ? 



GYNECOLOGIC EXAMINATION 1 9 

Finally — let the patient in a few words define and explain the 
annoyances and symptoms of which she complains and 
because of which she comes. 

Preliminary to the abdominal and pelvic examination, the con- 
dition of the lungs, the heart, and the state of the blood should be 
determined. 

EXAMINATION OF THE ABDOMEN 

For the gynecologic examination the patient should remove her 
corset, and should loosen all the bands about the waist. Ex- 
amination is performed with the patient in the lithotomy position 
with the knees separated by movable rests, in order to remove 
any strain upon the abdominal muscles. The bladder should 
be emptied into a commode, unless it is desired to first determine 
the condition of the urethra, in which event the urine is obtained 
with the aid of the catheter. Unless the rectum and sigmoid are 
empty a thorough examination cannot be made. 

The abdomen should be thoroughly examined and percussed 
and the condition of the abdominal wall, whether elastic or flaccid, 
should be noted, and the presence of separation of the recti muscles 
or the existence of a hernia should be looked for. Painful spots 
should be noted, particularly in examining the region of the gall- 
bladder and appendix and the points of Morris. If a line be 
drawn from the umbilicus to either anterior superior spine of the 
ilium, a point on each of these lines i 1 inches distant from the 
umbilicus corresponds to Morris's points. If the appendix alone 
is involved, the right point will be sensitive and the left point will 
not, while, if there is pelvic inflammation or marked involve- 
ment, both points will be sensitive. The presence or existence 
of movable or floating kidney on either side should be carefully 
looked into and the abdomen should be percussed to determine 
the existence of splanchnoptosis. The abdomen should be 
thoroughly palpated to determine the existence of a pelvic tumor 
or of a uterus enlarged by a tumor or by pregnancy, or to determine 
the presence of the uterus held close to the abdominal wall by a 
retro- uterine tumor or exudate. The fingers of either hand should 
press down into the pelvis to determine the existence of abdominal 
rigidity or to note the production of pain. After the conclusion 



20 



MEDICAL GYNECOLOGY 



of the subsequent examination the patient, while in a seated or 
standing position, should be further examined as to the existence 
of movable or floating kidneys and to note the outline of the ab- 
domen, especially if 
gastro - enteroptosis 
or very loose ab- 
dominal walls are 
present. 

I find the table 
illustrated in Fig. i 
of the greatest con- 
venience. With it 
the patient can be 
readily elevated in- 
to modified degrees 
of the Trendelen- 
burg position. The 
legs are supported 
by movable rests 
which swing the 
knees into a com- 
fortable position. 
Below the surface 
of the table is a 
large trough, nearly 
the full width of 
the table, which 
may be drawn out, 
and which readily 
catches the fluids 
poured out from a 
speculum or from 
the catheter when 
irrigating the blad- 
der. The fluid runs down this wide trough into a large round 
basin placed upon a framework underneath the table. 




Fig. i. — Examining table with adjustable movable 
leg-holders. Underneath is a wide trough which is 
pulled out during vaginal or bladder therapy and which 
carries fluids and cotton down to the basin below. A 
large leather cushion makes the lithotomy position 
exceedingly comfortable. The upper wing of the table 
can be raised to any angle. The lower end can be 
raised, with the patient on it, to a mild Trendelenburg 
position. 



GYNECOLOGIC EXAMINATION 



21 



INSPECTION AND PALPATION 

Vulva and Vagina. — The external appearance of the vulva 

should be noted and the condition of the skin and the hair-follicles 

as well as the skin of the thigh area can be observed. The large 

and small labia are then separated and the color of the vulva and 




Fig. 2. — Separation of the labia with the thumb and index-finger is an essen- 
tial step to clearly disclose the important structures of the vulva, and the urethra 
preliminary to bimanual examination. Careful examination of the vulva and its 
contained ducts, glands, and openings is of prime importance. 



the character of the mucosa are observed (Fig. 2). The exter- 
nal opening of the urethra is carefully looked at, the vestibule 
likewise, and redness or accumulations in the peri-urethral ducts 
are looked for. In nulliparae the fourchet is examined, and if 
these is an accumulation of discharge, it is wiped away by moist 



22 



MEDICAL GYNECOLOGY 



cotton sponges, so that 
9 



f 



n 



Fig. 3. — a, Platinum 
loop for taking secretion 
from the urethra, vulvar 
glands, ducts of Bartholin, 
vagina, cervix, b, Plati- 
num spoon for taking scrap- 
ings from the urethra, 
vulva, vagina, and cervix. 
c, Small spatula for the same 
purpose. 

dition of the levator ani 



the character of this part of the vulva is 
distinctly visible. The condition of the 
perineum is observed and the patient is 
told to press down as if at stool, in order 
to determine any protrusion of the an- 
terior or posterior vaginal walls. The 
opening of the ducts of Bartholin are next 
examined and flea-bite redness of their 
outer ends looked for. Pressure is then 
made on the glands of Bartholin and a 
smear taken of the secretion. Skene's 
glands are then brought into view, if possi- 
ble, by separating the lips of the external 
opening of the urethra, and if a discharge 
is present a smear is taken. The urethra 
is then massaged and a smear is taken of 
the secretion. If no secretion is obtained, 
and if symptoms point to possible involve- 
ment of the urethra, a platinum loop or, 
better still, a small platinum flat spoon 
sterilized over the flame, gently intro- 
duced, scrapes the urethral walls from 
behind forward (Fig. 3). 

After washing the vulva a loop or plati- 
num spoon takes a smear of the vaginal 
secretion. The external opening of the 
urethra is then washed with antiseptic 
solution and the urine is drawn off into 
a sterile glass for examination for albu- 
min, sugar, and for urea determination, 
microscopic examination of the sediment, 
and for the possible making of bacterial 
cultures or guinea-pig inoculations. 

The first and second fingers of either 
hand, preferably the left hand, are dipped 
in soapsuds and introduced into the 
vagina. They should first note the con- 
muscles, their elasticity; the fingers should 



GYNECOLOGIC EXAMINATION 23 

pass down along their lateral border toward the perineum and 
the degree of their firmness or laceration or flaccidity should be 
noted. The fingers are then introduced along the vagina, and the 
heat, smoothness, roughness, and sensitiveness of the vaginal mu- 
cosa should be determined. The fingers are then introduced into 
the fornices and the existence of bands or of scars running out 
from the lateral borders of the cervix should be looked for. 

The cervix is then palpated and the presence or absence of 
lacerations should be remarked. The size of the cervix and the con- 
sistence of the cervix should then be noted, and the character of 
the external os should be determined — normal, soft, smooth and 
velvety, rough or granular, small or large external os; and if 
large, whether it admits a finger. 

Uterus. — The position and size of the uterus should then be 
determined. The index and middle ringers are in the vagina, the 
thumb is over the clitoris, the two last fingers of the hand are folded 
upon the palm and make pressure on the perineum (Fig. 4). The 
elbow of the examining hand rests against the body or on the knee, 
which is flexed, the foot resting on a stool. The body is inclined 
forward and pushes the examining hand high up and presses the 
closed last two fingers against the perineum without any conscious 
exertion of the arm. The two internal fingers are then turned 
with their palmar surface upward to determine whether the 
fundus is in normal anteflexion, or in anteversion, or in pathologic 
anteflexion. Ofttimes the fundus can be readily felt, especially 
if the bladder has been emptied. 

The external hand presses with the palmar surface of the fingers 
upon the abdomen between the umbilicus and the symphysis. 
If the uterus is in anteflexion, it will be felt between the external 
and internal fingers, or else the pressure of the external hand will 
be distinctly felt by the internal fingers communicated by the 
body of the uterus (Fig. 5). The character of the anterior uterine 
wall should then be determined. The posterior wall of the uterus 
should be palpated by the external hand and its size, consistence, 
breadth, and thickness can be determined. The internal fingers 
are then passed first into one lateral fornix and then into the other. 
It is often valuable to use the fingers of the left hand in palpating 
the patient's left adnexa and the fingers of the right hand in pal- 



24 



MEDICAL GYNECOLOGY 



pating the right adnexa. The ringers are introduced into the 
lateral fornix and the external hand passes out from the fundus 
and then a little upward, pressing gently and firmly against the 




Fig. 4. — Correct position of patient and physician in making bimanual examina- 
tion. Resting the examining arm on the leg of the same side enables the body, 
by leaning forward, to push the examining fingers steadily and deeply into the 
vagina without conscious effort. The index and middle fingers are always intro- 
duced into the vagina when possible. 

abdominal walls in an effort to bring the tube and ovary between 
the fingers of the two hands. A normal tube can be felt with 
difficulty; normal ovaries, except in very obese women or women 
with resistant abdominal walls, can be readily palpated and their 



GYNECOLOGIC EXAMINATION 



25 



size and sensitiveness determined. In some cases, even with 
normally anteflexed uteri, the tubes and ovaries are descended or 
prolapsed postero-lateral to the uterus or even into the lateral 
area of the cul-de-sac of Douglas. 

If the uterus is not felt in anteflexion, the internal fingers are 
introduced into the posterior fornix to determine the existence of a 
retroflexion (Fig. 6). The fingers then feel, in the cul-de-sac of 
Douglas, the fundus of the uterus, and its continuity with the 




Fig. 5. — Position of the examining fingers in the vagina and the finding of the 
fundus uteri between the internal and external fingers when the uterus is normally 
flexed and the bladder is empty. 



cervix is determined. The adnexa of such a uterus are felt by 
introducing the examining fingers high up into the posterior 
fornix, and then palpating laterally toward the lateral pelvic wall. 
The external hand is relatively of little use in this manipulation, 
but pressure should be exerted in the lower part of the hypo- 
gastric region in order to press the ovaries nearer to the internal 
fingers. By deep pressure adnexa situated laterally, even if 
adherent, can be brought between the external and internal 
fingers, but many of such adherent tubes and ovaries cannot be 



26 



MEDICAL GYNECOLOGY 



palpated if they are adherent to the posterior wall of the broad 
ligament or to the lateral pelvic wall, or if, as so often happens, 
they are adherent to and covered by the sigmoid and other perito- 
neal adhesions. In some cases elevation of the patient into the 
Trendelenburg position enables such adnexa to be palpated. 

If the uterus is not found in anteflexion or retroflexion, it should 
be sought in retroversion with the fundus in the hollow of the 
sacrum or higher up. This means that the internal fingers must 




Fig. 6. — The examining fingers are in the posterior fornix palpating the fundus 
of a retrofiexed uterus and noting the continuation of the cervix into the fundus. 
In this manipulation the external hand is of little importance. 

be introduced high up into the posterior fornix, that the body 
must be pressed firmly against the elbow of the examining arm, 
and that the fingers should be introduced up toward the sacral 
promontory as when measuring the conjugate diameter in ob- 
stetric cases. If the uterus is not found in anteflexion or ante- 
version or in retroflexion, it must be retro verted (Fig. 7). The 
external hand then presses on the abdomen from the umbilicus 
down, and generally the uterus can be palpated, but very often the 
size, breadth, and thickness cannot be accurately made out. In 



GYNECOLOGIC EXAMINATION 27 

such cases the adnexa may be situated beyond the reach of the ex- 
ternal and internal fingers. 

The next step is to determine the mobility of the fundus if it 
is retro verted or retroflexed. The fingers are pushed high up 
into the posterior fornix and a retroflexed fundus should be lifted 
up. In freely movable cases the manipulation does not cause pain, 
but if the uterus or the adnexa are fixed by adhesions, this manipu- 




__e > o.s3iS_» 



Fig. 7. — The uterus is not found in anteflexion or anteversion. If it is then 
not found in retroflexion (as in Fig. 6), it must be in the position known as retrover- 
sion, and the internal fingers, if introduced deeply into the posterior fornix, can 
feel the straight continuation of the cervix into the fundus. 

lation is painful. To determine the mobility of the fundus, the 
second finger passes high up into the posterior fornix and lifts 
up the fundus, the index-finger is passed anterior to the cervix, 
and the cervix is steadily and constantly pressed downward and 
then backward. With this manipulation, unless the area of the 
internal os is very soft, the fundus will be elevated. If this man- 
ipulation is repeated gently but firmly several times, the fundus 
of a movable retroflexion, and surely the fundus of a retroversion, 



28 MEDICAL GYNECOLOGY 

will be elevated sufficiently to enable the fingers of the external 
hand pressing on the abdominal wall below the umbilicus to pass 
posteriorly to the fundus. Then by steady forward movement 
of these fingers toward the symphysis, accompanied by the pushing 
of the cervix backward and upward with the internal fingers, a 
movable retroversion and retroflexion can readily be brought 
into ante version or anteflexion. 

The above-mentioned manipulation of the fundus is often too 
painful to be carried out, and is often prohibited by adhesions of 
the posterior wall of the uterus or by adhesions of the adnexa. 
Adhesions of the posterior wall of the uterus repesent peritoneal 
bands, which may often be felt during this manipulation, especially 
if the internal fingers are passed high up into the posterior fornix. 
These perimetritic bands are sometimes stretchable and multiple, 
and must be distinguished from thickened or shortened uterosacral 
ligaments, which are only two in number, and which run back- 
ward and outward from the cervix. If such bands are not firm, 
and if the fundus can be brought somewhat forward so that the 
external hand can be behind it, further attempts at moving the 
fundus may be successful, but are generally prohibited either by 
pain, by firmness of the adhesions, or by adhesions of the adnexa, 
which thus limit mobility. 

A most important point in the examination is to determine not 
only the mobility of the fundus, but the mobility of the cervix, 
which depends on its attached ligaments, particularly the broad 
ligaments and the uterosacral ligaments. It is important to deter- 
mine the condition of the broad ligaments, of the uterosacral liga- 
ments, and of the posterior parametrium. Fresh or old infiltra- 
tions in the broad ligaments are felt more or less closely connected 
with the uterus or more or less closely connected with the pelvic 
wall. Such conditions often cover the tubes and ovaries or prevent 
their bimanual palpation. In other cases, one or other of the broad 
ligaments are sclerotic or shortened, with or without the existence 
of vaginal scars running from cervical tears over to the lateral wall 
of the vagina. These not infrequently pull the cervix toward their 
side and prevent its being pulled or pushed to the other side. 

The condition of the posterior -parametrium and the uterosacral 
ligaments is a question of very greatest importance. In some 



GYNECOLOGIC EXAMINATION 29 

cases, as a result of parametritis, the posterior fornix is short 
and sensitive and pressure causes pain. Attempts to lift the cervix 
upward show mobility to be limited and produce pain. If this 
condition is not marked, the fingers should pass high up into the 
fornices, and by a steady manipulation the uterus should be lifted 




J3o-s^> 



Fig. 8. — With the tip of the middle finger under the cervix in the posterior 
fornix, the uterus can be lifted up toward the abdominal wall and an anteflexed 
or anteverted uterus is brought into touch with the external fingers. This manipu- 
lation tests the mobility of the cervix, determines the degree of pain produced 
thereby, and puts the posterior parametrium and the uterosacral ligaments on the 
stretch so that the latter are readily palpated. If the uterus is retroverted or 
retroflexed both fingers must be introduced into the posterior fornix. 



upward (Fig. 8) and held with the index-finger, and the second 
finger, moving from one side to the other, often finds the utero- 
sacral ligaments lengthened and sensitive, or shortened and 
sclerosed and limiting the mobility of the cervix. 

The internal fingers should palpate the pelvic wall, passing 
as high up as possible into the hollow of the sacrum, and then to- 
ward the lateral pelvic wall to determine the presence of exudates 



30 MEDICAL GYNECOLOGY 

or infiltrates or the presence of adherent tubes and ovaries, or of 
pyosalpinx or of movable or fixed prolapsed cystic ovaries or 
movable or fixed small ovarian cysts. 

If, in the course of bimanual examination, the external hand 
feels a foreign body in one hypogastric region or the other, or 
in the median line between the symphysis and the sacrum, or above 
the true pelvis, we are concerned with the existence of a pregnant 
uterus, or of a fibroid uterus, or of a fibroid attached to the uterus 
by a pedicle, or of an ovarian cyst. We must determine whether 
we are dealing with an enlarged uterus (pregnancy or fibroid), 
or whether we are concerned with a cyst or solid tumor of the 
ovary or with a solid tumor attached to the uterine body by a 
pedicle (fibroid). The existence of pregnancy or fibroid uterus 
is determined by proving the continuity of the tumor felt by the 
abdominal hand with the cervix. This is done by gently palpating 
from above downward to the symphysis. Pushing upward on 
the tumor with the abdominal hand distinctly pulls the cervix 
with it. Tapping of the abdominal tumor with the hand is com- 
municated directly to the fingers applied to the cervix. Pushing 
the tumor to one side or the other moves the cervix distinctly. 

In the case of an ovarian cyst or a pedicled uterine fibroid the 
essential point is to prove the existence of a pedicle. This can be 
done by putting the patient in the Trendelenburg position. Push- 
ing up on the tumor, we may feel with the external hand and with 
the internal hand a space between the tumor and uterus, and may 
actually feel the pedicle. Pushing such ovarian tumors upward 
does not pull the cervix upward. Marked tapping of the tumor 
is not readily communicated to the cervix. If the uterus can be 
made out to be of normal size, of course the abdominal tumor is 
proved to be either an ovarian tumor or a pedicled fibroid. This 
differential diagnosis is often aided by grasping the cervix with 
volsella. By pulling down on the volsella, a separation of the 
uterus from the tumor and the feeling of the pedicle is rendered 
more easy. 

The differential diagnosis between pedicled fibroid of the uterus 
and solid ovarian tumor demands the finding and feeling of the 
pedicle, which is harder and firmer in the case of a fibroid than in 
the case of an ovarian cyst. 



GYNECOLOGIC EXAMINATION 



31 



The existence of ascites in conjunction with the presence of an 
abdominal tumor, or without its presence, and the determination 
as to whether the fluid is 
free or encapsulated, is 
an important point, but 
often very difficult of 
determination. 

Examination by 
Specula. — Examination 
of the cervix, vagina, and 
uterine cavity and treat- 
ment of the same are 
carried out with the aid 
of specula (Figs. 9 and 
10). The introduction 
of bivalve specula shows 
the color and character of 
the vault of the vagina 

and brings the cervix well into the field. The selected speculum 
should not be too long, else the fornix is too widely stretched and the 
cervix drawn high up and not readily reached. If the speculum 




Fig. 9. — Graves' bivalve specu- 
lum, which can be adjusted so as to 
give various degrees of separation 
of the anterior and posterior blades. 
When taken apart, the posterior 
blade is a good substitute for a 
Sims speculum. 




Fig. 10. — Brewer's bivalve speculum. 



is too small, then the lateral walls of the vagina bulge into the 
lumen of the speculum and the cervix is not readily seen 
nor treated. For examination of the vagina and for its treat- 



32 



MEDICAL GYNECOLOGY 



menj Ferguson specula are absolutely essential. When of the 
right size, anointed with soapsuds, and introduced with gentle 
rotatory motion, they give an excellent picture of the cervix, and 
by gradual withdrawal toward the vulva show the color, character, 

and lesions of the vaginal 
mucosa. 

The use of the bivalve 
speculum discloses the 
cervix. We see the char- 
acter of the outer cover- 
ing of the vaginal portion, 
the character of the ex- 
ternal os, the existence of 
erosions, or ulcers or ec- 
tropion. We see the 
character and color of 
the cervical discharge. 
The fornices are thor- 
oughly sponged with lysol 
or carbolic solution and 
some of the cervical secre- 
tion is taken and a smear made for microscopic examination. If 
the cervix is free of mucus, or if it can be gently freed of mucus, 
a thin platinum loop may sometimes be introduced into the cervix 
and a smear made. 




Fig. ii. — The Schultze tampon, made of 
cotton and introduced through a bivalve specu- 
lum and packed about the cervix, takes up dur- 
ing twenty -four hours the secretion from the cer- 
vix and uterus, gives us an idea of the amount 
and character of the cervico-uterine discharge, 
and furnishes the material for microscopic ex- 
amination for pus cells, epithelia, and bacteria. 




Fig. 12. — Long glass tube with ampulla and large rubber bulb to be introduced 
through a bivalve speculum and applied over the dried cervix to draw out by suc- 
tion the cervico-uterine discharge for examination. 



It is important to determine the character and amount of the 
cervical and uterine discharge, as distinguished from the vaginal 
discharge. For this purpose a fair-sized bivalve speculum is 
needed. The vagina and fornices are thoroughly cleansed with 



GYNECOLOGIC EXAMINATION 



33 




lysol or carbolic solution. A square piece of absorbent cotton 
three inches square and fairly thick is taken and a piece of strong 
thread is tied about it just tight enough to slightly indent the sides. 
The cotton remains flat. Another piece of thread is tied about 
the cotton at right angles with the first thread, 
the knot of both of these being tied at the mid- 
dle of the flat surface, and at the same point for 
each (Fig. n). The cotton is then introduced 
with the side reverse to the knot uppermost, 
and is brought over the external os. The four 
corners of this flat cotton tampon are then 
pushed upward snugly into the four fornices of 
the vagina, the speculum is carefully removed, 
and the string is left hanging out of the 
vagina. At the end of twenty- four hours this 
tampon is removed, preferably after introduc- 
tion of the bivalve speculum. Whatever secre- 
tion has been discharged by the cervix and the 
uterus during these twenty-four hours remains 
on the upper surface of the tampon. The 
mucoid elements are from the cervix. Pus 
thoroughly mixed with mucus means that the 
mucopurulent discharge has come from the 
cervix. One or more accumulations of pus 
free of mucus signify a uterine secretion. The 
distinction between the two can readily be made 
when the loop takes up portions of the discharge 
for the making of smears. The cervical secre- 
tion is thick and tenacious, while the uterine dis- 
charge is thick and not mucoid and is easily dis- 
tributed over the surface of the slide. Another 
method of obtaining cervical secretion, and 
sometimes uterine secretion, is the use of suction. A long tube the 
size of a test-tube, with an upper trumpet end made to fit over the 
cervix like the end of a breast pump, and with a rubber bulb like that 
of the breast pump at the other end, can be inserted through the 
bivalve speculum and placed over the external os after the cervix 
has been thoroughly dried (Fig. 12). One or several applications 
3 



Fig- 13.— Large 
powerful rubber 

bulb to be com- 
pressed and applied 
closely into the outer 
end of a Ferguson 
speculum which has 
been introduced and 
pressed snugly into 
the fornix about the 
cervix. By its suc- 
tion action it draws 
out the cervico- 
uterine secretion, 
and if applied for 
several minutes pro- 
duces a uterine hy- 
peremia which has 
the therapeutic value 
attributed to Bier's 
suction hyperemia. 



34 



MEDICAL GYNECOLOGY 



to the cervix draw out from the cervical canal a serous, mucoid, or 
purulent discharge, and cause edematous swellings around the 
external os. In addition to this, long pipets may be introduced 
into the cervix, and if the bulb attached is powerful enough an 
intrauterine discharge may be obtained. In practically all cases, 




Fig. 14. — Uterine sounds for determining the position of the uterus, the length 
of the uterine cavity, the character of the endometrium, and the size, character, and 
sensitiveness of the internal os. They serve almost the same purpose when passed 
into the urethra. 



however, the above-mentioned cotton pledget, the Schultze tampon, 
meets all the indications for obtaining the cervico-uterine dis- 
charge over a period of twenty-four hours. (See also Fig. 13.) 

Uterine Sound. — In determining the character, structure, and 
condition of the uterine lining, and the size and length of the 
uterine cavity, we are often compelled to palpate the inner 




Fig. 15. — Position of sound and hand as the first 
step in introducing the sound into a sharp anteflexion. 
Ordinarily the sound passes by gentle pressure into 
the anteflexed or anteverted uterus, when the con- 
cavity of the curve of the sound looks toward the ab- 
domen. 



surface of the uterus with the aid of a uterine sound (Fig. 14). The 
uterine sound is sometimes necessary to define the position 
of the uterus when this cannot be accurately determined bi- 
manually; to differentiate the uterus, by determining its position, 
from masses or tumors behind it or in front of it; to determine 
its length and thus corroborate the existence of a uterine fibroid 



GYNECOLOGIC EXAMINATION 



35 



as against an extrauterine tumor, if the uterus is found to 
be very much enlarged. By some, the sound has been used to aid 
in restoring a retroflexed uterus to its normal position, a manipula- 
tion which is fraught with much danger. As a rule, however, 
the use of the sound can be dispensed with. It is an instrument 
which can do much harm. It may carry in- 
fection existing in the cervix up into 




Fig. 1 6. — The hand describes a semicircle toward the right. The 
position of the hand and the rotation of the sound are shown. 



the uterus. When used, only the gentlest manipulations are per- 
mitted ; the vagina and cervix should be most thoroughly cleansed ; 
the speculum should be a sterile one and the sound most thoroughly 
sterilized. In some cases, without marked anteflexion, or without 
marked retroflexion, the sound readily passes forward or backward, 

or straight in the direction of a 

retroversion. The handle of the 

sound should be held 




Fig. 17 



-The third step, while the hand is describing 
the semicircle and rotating the sound. 



between the thumb and the first finger, and only the gentlest manipu- 
lation should be used. Ofttimes the sound does not slip past the in- 
ternal os into an anteflexed uterus. The tip of the sound should then 
be introduced with the concavity looking downward until the point 
reaches the internal os; then, by rotating and moving the handle 
in a circular direction, the hand holding the handle describes a 
half circle to the right until the handle is as high as a plane 



36 



MEDICAL GYNECOLOGY 



extending from the abdominal wall, when the handle should be 
gradually depressed and the point slips up without the use of force 
past the internal os into the uterus (Figs. 15, 16, 17, 18). The very 
opposite manipulation is used in introducing the sound into a 
sharply retroflexed uterus. The sound is introduced as far as the 




-n 



Fig. 18. — After the semicircle has been completed, the 
handle of the sound is depressed and the tip of the sound 
slips past the internal os into the uterus. The whole 
manipulation is done gently and quickly, without force, 
but with gentle pressure. The entire manipulation must 
sometimes be repeated more than once. 



internal os; the handle is held between the thumb and first 
finger, as high as a plane extending out from the symphysis; 
the handle is then swung in a large circle to the left until 
it comes down to a plane level with the table, when it is 
then slipped through the internal os into the uterus (Figs. 19, 20, 
21). It is often necessary to loosen the 
screw of the speculum and to pull the 
cervix down by volsellum before the 
sound will pass through the in- 
ternal os of a sharply 
flexed uterus. 



Fig. 19. — Position of hand and sound when 
introducing this instrument into a sharply retro- 
flexed uterus. Ordinarily the sound passes into 
a retroflexed uterus by gentle pressure when the 
concavity of the sound looks down toward the 
table. 




The sound determines: (1) the length and size of the cervix, 
the character of the constriction or stenosis of the external and 
internal os, and the sensitiveness of the same; (2) it determines 
the length and direction of the uterine cavity; (3) it informs us of 



GYNECOLOGIC EXAMINATION 



37 



the size of the uterine cavity and the thickness of its walls; (4) 
it informs us of the character of the inner surface of the uterus 
and aids in determining the presence of new-growths; (5) it 
determines the mobility of the uterus ; (6) it informs us of the sen- 
sitiveness of the uterine lining. Its use is 
contraindicated in pregnancy or on 
suspicion of pregnancy, in inflamma- 
tion of the uterus and its surround- 
ings, in hematocele, in purulent 
discharge from the uterus 
*^>- and vagina, in car- 




cinoma of the 



Fig. 20. — The hand describes a semicircle toward the left, at the 
same time rotating the handle. 



fundus, and during menstruation. It should never be used through 
a Ferguson speculum. 

Urethra and Bladder. — The introduction of the finger into 
the vagina, with palpation and manipulation and massage of the 




Fig. 21. — "When the semicircle has been completed and 
the handle has been brought almost to a level with the 
table, it slips by gentle pressure past the internal os. 



urethra along the anterior vaginal wall, shows the sensitiveness, the 
degree of infiltration of its wall, and the existence of areas of malig- 
nant induration and also expresses the urethral secretion (Fig. 

22). 



3« 



MEDICAL GYNECOLOGY 



The uterine sound, when gently introduced into the urethra 
and gently passed over its entire surface, determines its sensitive- 
ness, the presence of irregularities or new-growths, and the exis- 
tence of stricture, as well as the sensitiveness of the region of the 
internal sphincter. 

The diagnosis of the lesions in the urethra in chronic inflamma- 
tory conditions which do not yield to treatment and the diagnosis 
of the presence of new- growths demand the use of the endoscope, 
which is readily applied and readily used in the female. The 
endoscope shows the color and character of the mucosa, the exis- 




~&°sse-' 



Fig. 22. — Massaging the urethra to determine its character and sensitiveness 
and to express any secretion contained in its lumen or in the urethral glands for 
the purpose of microscopic examination. This step often discloses a chronic 
urethritis and is to be done several hours after the last urination. 



tence of plaques, of infected glands, of polyps, new-growths, and 
deep urethral caruncles. 

The examination of the bladder should be always preceded by 
thorough examination of the urine which, in many cases, combined 
with the symptoms and a history of the etiology, suffices for the 
purpose of treatment. In complicated cases, in stubborn cases, 
and when blood is present in the urine, the use of the Otis, Nitze, 
or Tilden Brown cystoscope is necessary. For routine examina- 
tion the Nitze or Otis examining cystoscope should be used (Fig. 
23). The bladder is first washed out and filled with a clear 



GYNECOLOGIC EXAMINATION 



39 



sterile water. The Nitze or Otis cystoscope is slightly anointed 
with sterile oil or glycerin, the cystoscope is gently introduced, 
the current is turned on, and the cavity of the bladder, to the 
minutest detail, is open to the eye, and all without discomfort to 




Fig. 23. — Otis examining cystoscope to be introduced into the bladder filled with 
sterile water after preliminary thorough irrigation of the bladder. The electric 
bulb furnishes a beautiful white light and the prism gives a splendid view of every 
bit of the bladder mucosa as the cystoscope is moved carefully forward and backward 
and rotated on its long axis. The patient is in a comfortable lithotomy position. 



the patient (Fig. 24). The Tilden Brown instrument, especially 
adapted in length for use in the female, is extremely valuable and 
simple. The use of this cystoscope is frequently needed in diag- 
nosing between involvement of the bladder and involvement of 




Fig. 24. — Examining cystoscope in the bladder previously irrigated and filled 
with water. The cystoscope is held with the left hand placed at a point which 
prevents the cystoscope from being introduced more than the desired distance, 
and so avoids pressing the electric bulb against the bladder mucosa. The elbow 
of the left hand is supported, if desired, by a rest attached to the lower end of the 
table. 

the kidneys, to determine involvement of the kidneys as evi- 
denced by the discharge of pus or blood from one or both ureters; 
for the purpose of catheterizing the ureters; for the purpose 
of examining the urine of the respective sides; or for determining 
the relative functional capability of the kidneys. 



4Q 



MEDICAL GYNECOLOGY 



Ureter. — The ureter can be palpated by turning the palmar 
surface of the fingers in the vagina upward and passing up to the 
level of the internal os, when external abdominal pressure aids in 
disclosing a cord passing externally and posteriorly and down- 
ward into the broad ligament. 

The ureters are readily catheterized with the aid of the short 
Tilden Brown catheterization cystoscope, of which ihe following is 
said: 

The sheath (Fig. 25, a) is an oval tube carrying the illuminating 
lamp and its insulated electric conductor; two stop-cocks for irri- 
gating; a screw for holding in place the obturator or the telescope. 




B 




Fig. 25. — Tilden Brown cystoscope of short length, fitted solely for use in the 
female bladder and for the purpose of catheterizing the ureters. It is of especial 
value for examining the base of the bladder and the openings of the ureters. 



The obturator is to be properly and securely in place when the 
sheath is passed into the bladder (Fig. 25). 

Irrigating Cocks. — As soon as the obturator is withdrawn the 
open end of the sheath is occluded by the thumb of the left hand; 
while the hose attachment for filling the bladder by gravity is 
fitted by the right hand to the right-hand cock. The fluid is 
emptied from the bladder either by removing the thumb from the 
open sheath or by opening the left-hand cock. This washing is 
repeated until the distending fluid returns perfectly clear. 

If one desires to have the bladder distended before passing the tele- 
scopic tube (Fig. 25, b) into the sheath, it can readily be secured with- 
out endangering escape of the medium by raising the ocular end of 
the sheath to such an angle that its open intravesical end rests on 
the trigonum; then on passing the telescope, it is important, just 



GYNECOLOGIC EXAMINATION 41 

before the latter has been pushed completely home, to lower the 
ocular end of the instrument, which at the same time lifts the 
vesical end and so prevents touching the bladder wall with the 
tip of the telescope. A little practice makes this easy to ac- 
complish. Should the distending medium, however, escape while 
inserting the telescope, or should one wish to change the medium 
at any time during the examination while the telescope is in place, 
it becomes necessary only to couple the irrigation hose to the 
right-hand nozzle and open the cock. 

The lamp is made so that it develops the least heat with the 
highest possible brilliancy. The safe point of illumination is 
when the light is almost white. If one is not familiar with the 
safe limit he should practice by turning on current slowly, watch- 
ing the appearance of the lamp filament, and stop at the point 
where the red changes into white light. Test before introduction 
and turn off until needed, also turn off light at intervals of two 
minutes each to prevent excessive heat. 

Source of current may be a six to eight cell battery with rheostat, 
or the incandescent lighting current; an accurately adjustable 
controller is to be used with the latter. 

Catheterization Attachment (Fig. 25, C). — Alongside of the tele- 
scope are two channels for guiding catheters; the entrance to each 
is provided with a thin rubber tube to fit snugly around the catheter 
to prevent leakage; a rubber collar serves the same purpose where 
the telescopic shoulder fits against the sheath. Exert slight pres- 
sure on the eye-piece while fastening the nut. The art of cathe- 
terization is difficult and requires careful study. No one should 
attempt catheterization unless he has acquired the necessary skill 
and practical knowledge in the simple branches of cystoscopy, for 
which purpose this instrument serves very well by omitting the 
catheters. 

As a preliminary step, and before any part of the examination 
has begun, the two canals of the catheterizing telescope should be 
properly equipped with sterile catheters having their tips all but 
protruding from the canals ; while their outer free ends are covered 
with sterile rubber caps, which both prevents the escape of the 
distending medium as well as the access of any fluid to their lumen 
until the removal of the caps (Fig. 25, C). For obvious reasons 



42 



MEDICAL GYNECOLOGY 



this is undesirable until after each catheter has been passed into 
its respective ureter. When bladder examination alone is to be 
made with this instrument the catheter canals are simply stopped 
with rubber caps. 

Examination per Rectum. — Examination per rectum is often of 
the greatest aid, especially in virgins. The index- finger, well 
covered with a finger-cot and vaselin, is passed high up and readily 
feels the cervix. Lifting the cervix upward, the external hand easily 
feels an anteflexed uterus. By this manipulation a retroflexed 




Fig. 26. — Tilden Brown cystoscope in the bladder filled with water and held 
almost at the angle requisite to passing the ureteral catheter into a ureter. The 
ureteral catheter is passed through the tube at A before the catheterization 
attachment (Fig. 25, C) is introduced into the sheath. These tubes, one on either 
side, are closed by rubber tips when this cystoscope is used simply for examination. 
The bladder is best filled with water before introducing the cystoscope with its 
obturator. The obturator is then taken out, the barrel is held upward at an acute 
angle, and the inner tube, without or with the ureteral catheters, is quickly intro- 
duced and fastened. 

uterus can be readily palpated. A parametritic exudate on the 
posterior wall of the pelvis or about the rectum can be made out. 
Prolapsed tubes and ovaries and cases of salpingo-oophoritis can 
be distinctly palpated, intrapelvic tumors can be felt, and their 
contour made out. The uterosacral ligaments and their character 
can be distinctly recognized. 

BACTERIOLOGIC METHODS 
Fixing Smears upon a Slide or Cover-glass. — In fixing 
specimens upon the slide or cover-glass for microscopic examina- 




Bosse. 



Fig. 27. — Showing the F. Tilden Brown cystoscope with the ureteral catheters 
introduced into the ureters. If it is desired to leave the catheters in place in the 
ureters for any length of time, the inner tube is drawn out gently while the catheters 
are pushed upward, and then the outer tube is withdrawn. 



GYNECOLOGIC EXAMINATION 43 

tion, it is essential that the smear be very even and thin. The 
smear is allowed to dry in the open air, in a thermostat, or by 
gently warming over a flame. It is then passed through the flame 
three times, if made on a cover-glass, or if on a slide until it is 
heated to a degree just tolerated by the back of the hand. 

Staining for the Gonococcus. — The gonococcus is an organism 
occurring in the shape of oval or coffee-bean shaped bodies. It is 
generally grouped in twos or fours, and resembles the German 
biscuit in appearance. It is found either free in the discharge 
from the urethra or in the secretion of the cervix, or, as is more 
often the case, it is inclosed within pus and epithelial cells. In 
examining specimens on cover-glass or slide, attention should be 
paid only to the intracellular gonococci, for they alone can be con- 
sidered diagnostic of gonorrhea. 

The secretion is taken upon a platinum loop, spread upon a 
cover-glass or slide, and fixed by the ordinary method. 

The staining is done in one of two ways: First, the simplest 
method is to stain the specimen for one minute in a i per cent, 
aqueous solution of methylene-blue, and then to wash it in water. 
The gonococci and the cells are both stained blue. If the char- 
acteristic diplococcus is found in the pus and epithelial cells by 
this method, one can be reasonably, but not positively, certain 
that the discharge is of a gonorrheal character. 

A refinement of this method is the employment of the eosinate 
of methylene-blue (Jenner). In this stain the organisms are 
stained blue, while the granules of eosinophilic leukocytes, which 
are usually present in large numbers and which are considered to 
be a characteristic feature of the gonorrheal discharge, appear as a 
bright or brownish red. The smear is immersed five minutes in 
this stain, washed and replaced in water, dried with filter-paper, 
and mounted. 

The second, known as the Gram method, is more diagnostic 
than the above, because it differentiates the gonococcus from other 
diplococci which may be present in pathologic secretions. The 
smears are fixed by heat and stained in a solution of gentian- 
violet (10 parts saturated alcoholic solution of gentian- violet to 
90 parts of 25 per cent, solution of carbolic acid — Fraenkel). 
•The solution should be placed in a watch-glass and the smear 



44 MEDICAL GYNECOLOGY 

allowed to rest upon the surface of the stain for three minutes. 
It is then blotted with filter-paper and without washing is covered 
with Lugol's solution (i grain of iodin, 2 grains of potassium 
iodid, and 300 c.c. of distilled water) for two minutes, then blotted 
with filter-paper and washed immediately in 95 per cent, alcohol for 
thirty seconds, or until the blue stain ceases to come away, when 
it is at once washed in water and counterstained with an aqueous 
1 per cent, solution of Bismarck-brown or of acid fuchsin. By 
this method the gonococci are stained brown or red, depending 
upon the counterstain used, while the other cocci, which may be 
present in the discharge, are stained blue. 

Fixing Slide for Tuberculosis Stain. — In staining for the 
bacillus tuberculosis the smears of the discharge are fixed in the 
ordinary manner and are stained for one minute to three minutes 
in Ziehl-Neelsen's carbol-fuchsin stain (90 parts of a 5 per cent, 
solution of carbolic acid and 10 parts of a concentrated alcoholic 
solution of fuchsin). While staining, the spread is held over a 
flame until steam appears, and is kept there without being al- 
lowed to boil. It is then blotted and placed either in a 20 per 
cent, solution of nitric or of sulphuric acid for about one-half 
minute, when it is, without washing, placed in 95 per cent, al- 
cohol and moved to and fro until the preparation loses all its red 
color. It may, however, be necessary, in order to facilitate this 
latter change, to repeatedly re-immerse for a few seconds in the 
acid solution and then again in alcohol. After decolorization it 
is counterstained by a concentrated solution of methylene-blue 
for a few seconds, then washed off in water and mounted in balsam. 
The tubercle bacilli will be stained red and all the other bacteria 
and cellular elements will be stained blue. 

Preparation of Centrifuged Sediment of Urine for Mi- 
croscopic Examination. — The sediment is usually examined for 
crystals, casts, cellular elements, and for bacteria. The cellular 
elements comprise leukocytes, erythrocytes, epithelial cells from 
the bladder, ureter, or kidney, and shreds of tissue from a neo- 
plasm. 

It is sufficient in demonstrating casts or crystals to place some 
of the sediment under a cover-glass and examine without further 
preparation. 



GYNECOLOGIC EXAMINATION 45 

In examining for pathogenic bacteria, including tuberculosis, 
the sediment should be spread upon several slides or cover- glasses 
and allowed to dry slowly either in the thermostat or in the open 
air. They should be covered to protect them from dust, and the 
amount of sediment on each slide should not be too great in quan- 
tity, so as to avoid too thick a smear or spread. If the smears are 
too thick, a film is formed which will not adhere to the glass. 
After drying, pass through a flame, as is done ordinarily in fixing 
smears, and then stain. 

This method will stain the cells as well as the bacteria; but if 
special attention is to be paid to the cellular elements, it is better, 
after the spreads are dried, to fix them in a solution of equal parts 
of strong alcohol and ether, or 5 per cent, formalin, anywhere from 
five to ten minutes, and then wash in water. This likewise ap- 
plies to the fixation in preparation of any shreds of tumor tissue 
which may be found in the sediment or floating in the urine. 
Methylene-blue and eosin or hematoxylin and eosin may be used 
as a stain for the tissue. 

When tuberculosis is suspected, the sediment should be ob- 
tained from a catheterized specimen of urine in order to avoid 
confusion with the smegma bacillus. If this is impossible, the 
spread should be stained with carbol-fuchsin and decolorized in 
acid and alcohol and then, before counterstaining, should be placed 
in 95 per cent, alcohol for at least twelve, and better twenty-four, 
hours. Then counterstain, and if any red stained bacilli remain, 
they are in all probability the tubercle bacilli. 

Cultures for Gonococci. — The gonococcus grows best upon 
serum-agar media. A small loopful of the discharge is trans- 
ferred from a platinum loop to a platinum spatula and drawn or 
streaked across the surface of a serum-agar culture plate, or the 
loopful may be placed at one point on the surface of the plate and 
streaked across with the spatula. As many as five or six streaks 
may be made on one plate, and the individual colonies of gono- 
cocci will subsequently be found along the line of the streaks last 
made. 

Cultures from Urine. — Urine from which cultures are to be 
made must be obtained by catheter in a sterile flask or bottle, and 
then sent to a laboratory for bacteriologic examination. No 



46 MEDICAL GYNECOLOGY 

chemical substance should be put in the urine with the idea of 
preventing decomposition. 

Inoculation of Guinea-pigs for Tuberculosis. — The urine 
to be used for inoculation must be obtained by catheter in a sterile 
receptacle and allowed to stand until a sediment has formed. 
This sediment is then removed and centrifuged in a sterile tube. 
It is well, when possible, to wash the sediment several times with 
sterile normal salt solution, especially if the inoculation is to be 
intraperitoneal. After the sediment has been concentrated as 
much as possible by centrifuging, it is drawn up into a syringe and 
the guinea-pig inoculated either intraperitoneally, under the integ- 
ument of the abdomen or of the inner surface of the thigh. Shav- 
ing of the skin and washing with some antiseptic solution is all 
that is necessary in the preparation of the guinea-pig. 

The inoculation under the skin is, as a rule, preferable to intra- 
peritoneal injection, for the reason that there is less chance of 
killing the animal by sepsis. 

Occasionally the sediment may be too thick to be drawn into 
the syringe, in which case it will be necessary to dilute it, either 
with sterile normal salt solution or with sterile bouillon. As a 
rule, 2 c.c. of either the sediment or its suspension is sufficient for 
the test. It is essential, after the guinea-pigs have been inoculated, 
that the animals be kept under the best possible hygienic condi- 
tions. If tuberculosis develops, the animal will generally die 
anywhere from within four to six weeks. If it lives after the ex- 
piration of this time, it should be killed and the autopsy per- 
formed. 

If the animal has been inoculated subcutaneously, either in the 
abdomen or thigh, inguinal glands will generally appear and grow 
quite large within two or three weeks if tubercle bacilli are present. 

Staining for the Spirochaeta Pallida (Schaudinn). — It is es- 
sential in examining spreads for the Spirochaeta pallida that they 
be made very thin. The discharge from an ulcer or from the 
initial lesion may be examined, but it is better, after first re- 
moving the discharge from the surface, to get the serum which 
may be expressed from the lesion. The spread is allowed to dry, 
then fixed in 95 per cent, alcohol for one hour, then placed in 
Giemsa's stain (Griibler) for ten minutes to one hour; wash in 



GYNECOLOGIC EXAMINATION 47 

water, dry with filter-paper, and mount in balsam and examine 
with the immersion lens. 

The spirochete are from 4 to 14 mm. in length, very thin and 
delicate, pointed and drawn out to a fine filament at the end. They 
have from six to fourteen convolutions and they are sharp, narrow, 
and screw-like. They have very little affinity for the anilin dye 
and hence stain very faintly. It requires very careful search to 
detect them. 



METHODS EMPLOYED IN MEDICAL TREATMENT 

THE URETHRA 

In the treatment of inflammatory conditions of the urethra a 
glass pipet of a greater diameter and length than a straight eye- 
dropper, and with a large bulb, fulfils all indications (Fig. 28). 
When introduced half-way into the urethra, gentle pressure on the 
bulb bathes the posterior half of the mucosa, the fluid flowing into 
the bladder. As the tip is pulled out a slight distance, pressure 
on the bulb forces the fluid into the urethra, but it returns extern- 
ally, bathing the anterior part of the urethra. When strong solu- 
tions are used, it is advisable to inject salt solution or some antiseptic 
solution into the bladder to prevent the irritation of this organ by 




Fig. 28. — Glass pipet with fair sized rubber bulb employed for injecting various 
solutions into the urethra in the treatment of urethritis. Before injecting strong 
solutions into the urethra the bladder should be filled with some fluid to dilute what- 
ever of the drug injected into the urethra may pass into the bladder. 



the silver fluids or strong solutions which may enter it from the 
pipet. 

Wooden or metal applicators wrapped with cotton and dipped 
in various solutions may be introduced into the urethra (Fig. 29). 
Better still, the tip of a Braun intrauterine syringe is covered with 
cotton and introduced into the urethra. The fluid in the barrel 
is then injected and the cotton becomes saturated with the medi- 
cament. The tip may be withdrawn and the cotton may be left 
in situ for any desired length of time. 

In some cases of urethral involvement it is necessary to dilate 
the urethra, and to follow the dilatation by local applications. Hegar 
dilators, such as are used for dilating the cervix, fulfil all the indica- 
tions. 

In the treatment of chronic conditions it is sometimes necessary 

48 



METHODS EMPLOYED IN MEDICAL TREATMENT 49 

to introduce into the urethra medicated pencils or bougies made of a 
base consisting of cacao-butter or cacao-butter and talcum, or gly- 
cerin. 

The urethra may be irrigated by injecting fluids directly into the 
bladder without the aid of a catheter. The syringe is protected 
by a rubber tip, and this procedure can be readily carried out. 
The patient may pass this fluid, and thus the urethra is again 
washed with the desired medication. 

In very chronic cases, where the tubular endoscope is needed 



Fig. 29. — Wooden and metal applicators to be covered -with a thin layer of 
cotton for applying various solutions to the urethra when long contact of the solution 
with the urethral mucosa is desired. 



also for diagnosis, topical applications or cauterization may be 
made to the involved areas with the aid of such a tubular instru- 
ment. 

THE BLADDER 
In the treatment of involvements of the bladder, irrigations, 
instillations, and topical applications are used. Irrigations are 
best carried out by the use of rubber catheters with trumpet- shaped 
outer ends. A large piston syringe made of glass, with or without 
metal trimmings, and containing several ounces is all that is needed 
(Fig. 30). With such a syringe the fluid can be injected with 
varying degrees of pressure. By removing the syringe the fluid is 
readily drained out. Another value of the piston syringe is that 
we can gage the capacity and resistance of the bladder, and in 
the treatment of chronic cases of "shrunken bladder" steady 
pressure can be used to distend the bladder (Fig. 31). By in- 
creasing the amount of fluid injected at each sitting, in the course 
of weeks or months the capacity of the bladder can be very much 
4 



5° 



MEDICAL GYNECOLOGY 



increased. The piston syringe gives us the ability to accurately 
judge the amount of fluid injected. Such glass syringes can be 
readily kept clean and sterilized. Instillations are made with this 




Fig. 30. — Piston syringe used for injecting fluids through a rubber catheter into 
the bladder for irrigation or treatment. With it, the amount injected can be con- 
trolled and varying degrees of force can be used for distending the bladder, a pro- 
cedure which is often of therapeutic importance, especially in the case of " shrunken 
bladder." 



syringe and a rubber catheter, or with the glass pipet introduced 
through the urethra into the bladder. The bladder may be irri- 
gated with the aid of a glass funnel attached to a rubber tube, using 
then a rubber or glass catheter. 




Fig. 31. — Shows piston syringe connected with rubber catheter in the act of 
injecting fluid into the bladder. The trough of the table, pictured in Fig. 1, catches 
the fluid as it is allowed to flow out through the catheter. 



Topical applications in the treatment of solitary ulcers or single 
or multiple tubercular foci, or for the painting of the trigone alone,, 
rarely demand the use of the Kelly cystoscope. 



METHODS EMPLOYED IN MEDICAL TREATMENT 5 1 

GLANDS OF THE VULVA AND URETHRA 

These are numerous small glands in the vulva, especially about 
the urethra, in the vestibule, and in the fossa navicularis, which 
when infected secrete a purulent or mucopurulent discharge, with- 
out these glands taking the form of pustules. 

These are infiltrated, swollen, suppurating follicles which must be 
destroyed with the silver stick or the actual cautery. These are 
frequently present with a chronic gonorrheal vulvitis and often 
escape attention. 

In the treatment of infections of the glands of Skene, a hypo- 
dermic needle and syringe are used, the needle having a smooth 
dull tip. It is introduced into the duct and various of the silver 





Fig. 32. — Knives and tube, modified by Bierhoff, to be used for 
splitting up the ducts of Skene or any urethral glands when chroni- 
cally infected and resisting other therapeutic measures. 

salts may be injected. If this fails to correct the condition, the 
urethra should be dilated, the ducts should be split open and 
cauterized with acids or with the cautery. This treatment can 
usually be done with the aid of cocain. 

The ordinary endoscopic tube is of little value for opening 
paraurethral passages situated near the external meatus. Bierhoff 
has devised a fenestrated endoscopic tube, the slit being 2 mm. 
wide. It is inserted so that the fenestrum lies directly over the 
orifice of the infected duct. The tube in this way protects the 
remaining circumference of the urethral wall (Fig. 32). 

The knife is inserted into the duct, and it may be slit along its 
whole length without danger of injuring the rest of the urethral 
wall, or else a fine probe may be passed into the duct and incision 
made upon it. 



52 MEDICAL GYNECOLOGY 

The tube is introduced with the obturator in place. On with- 
drawing the obturator the opening of the duct is brought into the 
slit and then the incision is made. 

Treatment is often necessary in the involvements of the ducts 
and glands of Bartholin. If it is desired to use applicators, the 
outer opening of the duct must be incised under cocain. After 
this is healed, local applications to the duct or injections into the 
gland may be made. In chronic cases which do not yield to treat- 
ment, the gland may be injected with solutions with the aid of a 
hypodermic needle, the needle being introduced straight into the 
gland through the vulvar mucosa without passing through the 
duct. 

In abscess of the gland, free incision is made, followed by irriga- 
tion and cauterization to destroy the so-called pyogenic membrane. 
Iodoform packing is used and kept in place by sutures. Healing 
generally takes place. In chronic swelling of the gland and in 
cysts of the gland of Bartholin the whole glandular structure must 
be excised. 

THE VAGINA 

Treatment of the vagina may be carried out by the use of medi- 
cated vaginal douches, by bathing with the aid of the Ferguson 
speculum, by introduction into the vagina of tampons, or by the 
application of drugs with the aid of other specula. 

Douches. — Douches may be of various temperatures and con- 
tain any of the various antiseptic, astringent, or soothing solutions. 
Cool temperatures are to be used in acute inflammation, tepid 
in subacute, and warm or hot in chronic involvements of the vagina. 
The drugs used are healing lotions or antiseptic fluids, or astringent 
remedies. 

Douches are especially used in the acute stages of vaginal in- 
flammations, and are now in general use for cleansing purposes 
and to aid in the correction of vaginal and cervical irritations. 
Their best purpose is to supplement local treatment by the Ferguson 
baths. 

In the use of the douche, glass tips or tubes are desirable (Fig. 
33). The douche is best taken in a lying position, especially if the 
effect of temperature is desired. The patient should then lie 



METHODS EMPLOYED IN MEDICAL TREATMENT 



53 




quietly for fifteen minutes to one-half hour. The douche should 

not be given at too high a pressure. When 

hot, it is very valuable in excessive bleeding 

and in stubborn inflammation of uterus and 

adnexa. It may be given once or twice daily, 

but with a marked discharge as often as four 

to six times, especially in acute conditions. 

It the patient is careful and cleanly, a 
douche with tepid water during menstru- 
ation is not contraindicated. 

Ferguson's Speculum. — At least three 
different sizes of Ferguson specula, of a length 
of 12 cm., should be in use. An internal ex- 
amination should precede the use of the 
speculum in order to judge the size and 
length of the vagina and the size and resist- 
ance of the introitus (Fig. 34). 

The speculum, well disinfected, should be 
taken in the right hand. The left hand 
separates the labia minora. With the aid of 
the thumb and two first fingers this manipu- 
lation gives a distinct view of the hymen, vestibule, and periurethral 
glands, the urethra and the fossa navicularis. The speculum is best 

moistened with soap- 
suds. The point of the 
speculum is introduced 
with pressure against 
the posterior vaginal 
wall and perineum so 
that the urethra is not 
pressed on (Fig. 35). 
With a slight rotary 
movement of the 
speculum it is pressed 
forward and directed 
at first horizontally, 
and then with its point 
directed downward. 



Fig- 33.— Glass 
douche tips to be at- 
tached to the tubing of 
a fountain rubber bag 
when taking vaginal 
douches. 




Fig. 34. — Ferguson speculum for clear examina- 
tion of the cervix and vagina, for giving vaginal baths 
and applications. Through it the cervix may be scari- 
fied or ovula of Naboth may be opened. Through it 
the long vaginal tampon (Fig. 48) may be introduced. 
When the speculum is drawn out slowly, the vagina 
may be dusted with powder with the aid of the 
powder-blower (Fig. 49). Into its outer end the 
large bulb (Fig. 13) may be firmly introduced and 
a powerful suction action may be exerted on the 
cervical and uterine canals or a marked uterine hy- 
peremia may be produced (Bier's hyperemia). 



54 



MEDICAL GYNECOLOGY 



The vaginal walls may be looked at as the speculum is being 
introduced, or else the cervix is first brought into the field of view 
and the vaginal walls are examined as the speculum is drawn 
forward. 




Fig. 35. — The method of introducing the Ferguson speculum. The speculum 
is made slippery by soapsuds. The labia are separated by the thumb and index- 
finger of the left hand. The tip of the speculum is placed on the posterior wall of 
the vaginal opening, the speculum being held at the angle indicated. The tip of 
the speculum is pressed down firmly on the posterior vaginal wall and by a gentle 
rotary motion the speculum is introduced into the vagina. The diameter of the 
speculum must be fitted to the size of the vaginal outlet as determined by the con- 
dition of the perineum and the levator ani muscles. 



The anterior and posterior vaginal walls lie close together, and 
are being spread by the introduced speculum. Hence, a very good 



METHODS EMPLOYED IN MEDICAL TREATMENT 



55 



view is given as this instrument is being first introduced. The 
cervix appears smaller in this speculum than it does in the bivalve, 
and cervical tears appear very slight. 

No intrauterine manipulation can be attempted with this 
speculum. It is used for the examination of the vagina and the 
vaginal portion of the cervix. With this speculum scarification 
of the cervix can be done, ovula of Naboth may be opened, and 
drugs may be applied to the vaginal portion of the cervix. 




Fig. 36. — Half section showing the Ferguson speculum in place with fluid poured 
into it. Only that part of the vagina and cervix seen beyond the tip of the specu- 
lum is touched by the introduced fluid. Only the cervix can thus be bathed if 
desired. 



A Ferguson speculum introduced into the vagina discloses the 
cervix, and when gradually drawn out gives a clear picture of the 
vaginal mucosa. During this manipulation the vagina should be 
washed and thoroughly dried. One advantage of the Ferguson 
speculum is that it permits the cervix or the upper part of the 
vagina to be bathed without touching, if so desired, the lower part 
of the vagina (Fig. 36). When firmly introduced and pushed into 
the fornices, fluid is poured into it and the cervix is thoroughly 
bathed. If the speculum is held firmly, none of the fluid finds its 



56 



MEDICAL GYNECOLOGY 



way between the speculum and the vaginal wall. The fluid is then 
poured out by depressing the outer end of the speculum and 
drying the cervix with cotton. If it is desired to bathe the 
whole vagina, the speculum is gradually drawn out close to 
the perineum or to the outer end of the vagina, by which man- 
ipulation the vaginal wall is stretched, folds are opened out, and 
every bit of the surface comes in contact with the medicated fluid. 
During this procedure the outer end of the speculum is lifted up 




Fig. 37. — Angle at which Ferguson speculum is held and 
drawn out, after the fluid has been poured into it, in order to 
thoroughly bathe the entire vaginal canal. The speculum is 
drawn out and pushed in several times. 



so that the speculum is at an angle of 45 degrees to the table (Fig. 
37). By depressing the outer end of the speculum, after it has 
again been pushed up into the fornices, the perineum and anus are 
kept free from the solution as it runs out of the speculum (Fig. 38). 
I have used a Ferguson speculum made of the form and size of 
the various Kelly cystoscopes, but without the handle, for ex- 
amining the vagina and portio in infants and children, and for 
the purpose of giving them vaginal baths with the various silver 
salts (Fig. 39). The vagina of children is best irrigated by intro- 



METHODS EMPLOYED IN MEDICAL TREATMENT 



57 



during a rubber urethral catheter, to which is attached the tubing 
of a fountain syringe or a piston syringe. By this method, if 
the two halves of the vulva are brought together by the thumb 
and first finger of the hand, the vagina is distended, the folds are 
opened out, and a thorough cleansing and medical application 
is made. The same method of examination and treatment applies 
in the case of virgins. No injury to the hymen occurs in either 
case. In the treatment of the vagina of children straight or 




Fig. 38. — The outer end of the speculum is depressed sharply after 
being slightly drawn out, and the fluid used is poured out either into 
the trough of the table or into a glass held under the speculum. 



curved eye-dropper pipets can be used without injury to the 
hymen. 

The Sims speculum (Fig. 40) is used with the patient lying 
on her left side in the so-called Sims position. The patient lies 
on a table or sofa on her left side with the left arm hanging over 
the left edge of the table and the thorax turned toward the table 
surface; the knees are bent and flexed sharply and drawn up, 
the right one higher than the left ; the buttocks are near the edge 
of the lower left corner of the table. The large labia are drawn 
up by an assistant, and the physician introduces one or two fin- 
gers into the vagina up back of the cervix. On this finger or 



58 



MEDICAL GYNECOLOGY 



Fig. 39. — Tiny vaginal 
Ferguson speculum for use 
in infants and small chil- 
dren, for the purpose of ex- 
amination and treatment of 
the vagina and portio in 
gonorrheal vulvovaginitis. 
This procedure is the same 
as in adults and no harm is 
done to the hymen. It may 
be used readily in the ure- 
thra of the adult female. 



between these two fingers the proper end of the speculum is intro- 
duced, and then turned so that its tip passes toward the hollow 

of the sacrum. The assistant takes hold 
of the other end and pulls it backward, 
pressing on the perineum. Air enters the 
vagina and bulges it out. The anterior 
vaginal wall is held back by a depressor, 
and if a volsellum is introduced and the 
cervix is grasped by it, an excellent view 
is obtained of the cervix and fornix. 

An objection to the Sims speculum is 
that its use implies assistance; hence, the 
bivalve is better. In rare cases of re- 

trodisplacement of the uterus it is difficult to get the cervix into view 

with a bivalve speculum and a Sims 

speculum in the Sims position is 

helpful. 

Bivalve Speculum. — In intro- 
ducing the bivalve speculum the 

labia are held apart by the fingers 

of the left hand (Fig. 41). The 

speculum is introduced with the 

blades closed, the blades looking to 

the right and to the left. Before 

introduction the blades should be 

smeared with vaselin or soapsuds. 

When introduced in this position, 

about one-half of their length, they 

are slowly turned so that the blades 

look up and down and are parallel 

to the anterior and posterior walls 

of the vagina. The outer end of 

the speculum is then elevated and 

the inner end is depressed firmly 

downward so that the tip of the speculum passes back of the cervix 

into the posterior fornix. The blades are then separated a slight 

distance, and at the same time the outer end is depressed and 

drawn slightly outward, so that the upper valve may slip over the 




Fig. 4.0.^-Sims speculum. Its 
use, as a rule, implies the aid of a 
nurse or an assistant. 



METHODS EMPLOYED IN MEDICAL TREATMENT 



59 



tip of the cervix into the anterior fornix. The screw is then 
turned until the blades are far enough apart to give a good view 
of the cervix and the fornices (Fig. 42). 

Abel's speculum (Fig. 43) is helpful when doing an intrauterine 
packing, especially in abortion, in order to keep the gauze from 
contact with the external genitalia and the vulva. 

Garrigues' weighted speculum is of aid in doing a curettage, 




Fig. 41. — In introducing the bivalve speculum the labia are separated by the 
thumb and index-finger of the left hand; the right hand holds the speculum as in- 
dicated. The blades are close together and, covered with soapsuds, are introduced 
so that the upper edge does not press against the urethra. When introduced as far 
as the two fingers held on either side of the two blades permit, the speculum is turned 
so that the blades lie in a horizontal plane. The outer end of the speculum is then 
elevated so that the tip of the blades passes under the cervix. The blades are then 
separated. 

for no assistance is needed to hold the posterior speculum in place, 
and the operator holds either the anterior speculum or the volsellum 
with the left hand. Edebohls' speculum, with a small pail at- 
tached, is very serviceable (Fig. 44). 

Tampons. — Tampons are made of cotton or wool or wool 
covered with gauze. A piece of cotton or wool of the desired size 
is taken and tied with a piece of string. The tampon is then 
doubled on itself and the free ends are immersed in glycerin, 



6o 



MEDICAL GYNECOLOGY 



ichthyol-glycerin, iodoform- glycerin, medicated lanolin, or any 
other medicament, and passed through the speculum with the 
aid of a long dressing forceps (Fig. 45) up to or around the cervix. 
Tampons are used either to apply drugs to the cervix, to apply 

glycerin for its depleting effect, to 
support the uterus, or to stretch 
the posterior fornix, the utero- 
sacral ligaments, or adhesions in 
the cul-de-sac of Douglas. Gen- 
erally one is introduced covered 




Fig. 43. — Abel's speculum. Its 
broad lateral flanges completely cover 
the labia. When packing the cervix 
and uterus with gauze, it prevents the 
sterile gauze from coming into contact 
with any part of the labia or vulva 
and thus insures perfect asepsis. 




Fig. 44. — Edebohls' self-retaining 
speculum, which is of great service when 
performing curettage or intrauterine 
packing without assistance. The pail, 
partly filled with water, serves as the 
weight to keep the speculum in place 
and catches the fluids and scrapings. 



with medicated glycerin and a dry one is introduced after to keep it 
in place. Two, three, or four of such small tampons may be intro- 
duced into the posterior fornix and anterior fornix, and then kept 
in place by a large one introduced after them or by gauze packed 
into the vagina. The strings about the tampon are made long 




Fig. 42. — Bivalve speculum in place. Through it the cervix is seen, ulcers, 
erosions, or new-growths of the portio are observed, and the color and character of 
the cervical discharge are noted. Through the bivalve speculum suction can be 
exerted with the tube and bulb of Fig. 12, and then cervical and uterine smears for 
microscopic examination are made. The sound may be introduced, intracervical 
and intrauterine applications and irrigations can be carried out, intrauterine 
electrodes can be introduced, scarification of the cervix can be done, test excisions 
from the cervix and test scrapings from the uterus can be obtained, and vaginal 
packing with glycerin and gauze or with powders and gauze can be carried out. 



METHODS EMPLOYED IN MEDICAL TREATMENT 



6l 



enough to extend out of the introitus so that they may be removed 
at the end of twelve or twenty-four hours. 

Wool tampons are more elastic and give better support to the 




Fig. 45. — Dressing forceps of proper caliber and curve. It is used in any and 
all of the procedures implied in the treatment of the cervix and vagina with the aid 
of the bivalve or Ferguson specula. It is also to be introduced into the uterus 
when packing it with gauze. 



uterus if this is the desired purpose. One or more of such tampons 
covered with the desired medicament may be used, or one long 
strip, with a string tied about it, may be used of a size sufficient 
to be packed in the fornices and to fill 
the vagina. This wool is often irritat- 
ing, but when its use is desired it may be 
covered with gauze. 

Instead of using several tampons, each 
separately tied by a string, we may use 
two, three, or more tampons, attached to 
each other at various distances by thread 
or string and packed in one after the other. 
They are easily removed by pulling on the 
string of the last one. 

In most cases I have discarded the use 
of cotton or wool and use gauze instead; 
soft gauze in strips 6 or more inches wide 
and of any desired length meets the re- 
quirements. The desired glycerin mixture 
is poured into the speculum (Fig. 46) and 
one long strip of gauze is packed gently or 
firmly into the lateral and posterior for- 
nices and the unused end is allowed to hang out over the posterior 
wall of the speculum. Another strip, somewhat shorter, is then 
packed into the anterior fornix (Fig. 47). Then the two unused 




Fig. 46. — Measuring glass 
used in pouring glycerin in- 
to the bivalve speculum and 
in pouring any desired solu- 
tion into the Ferguson 
speculum. 



62 



MEDICAL GYNECOLOGY 



portions are gently but firmly introduced together into the upper 
part of the vagina, and loosely into the lower half of the vagina. 
This packing is held in place by pressure with dressing forceps 
and the speculum is removed. The advantage of this is firmer 
support to the uterus, excellent stretching effect on sclerosed bands 
in the posterior fornix and on the cul-de-sac of Douglas, and good 
drainage of the serous effusion produced by the glycerin. 

Tampons introduced into the vagina are generally applied about 
the cervix and in the fornices to permit of medication of the cervix 
and its canal and to exert a depleting or dehydrating action on the 
pelvic organs. Tampons for the treatment of the vagina itself 




Fig. 48. — Long vaginal tampon, made of cotton covered with sterile gauze, to 
be introduced into the vagina through the bivalve or, better, through the Ferguson 
speculum. This tampon when dusted with powder is of great aid in applying any 
desired dry medicament to the vaginal walls and in keeping them dry. 



consist of cotton rolled to any desired diameter and cut off to a 
length a little less than the length of the vagina. This is 
then covered by two or three layers of gauze and a string is tied 
about either end to keep the gauze in place. The string at one 
end is left long enough to permit this tampon to be pulled out 
(Fig. 48). If such a tampon be dusted with various powders and 
introduced into the vagina, preferably through a Ferguson specu- 
lum, it brings the drug in constant contact with the vaginal mu- 
cosa and keeps the vaginal mucosa dry. 

The vagina may be packed throughout its whole length with 
bichlorid gauze, with iodoform gauze, or with gauze soaked in 
any of the silver salts, in astringent solutions, or any desired 




B°SS6^ 



Fig. 47. — Introducing gauze, with dressing forceps, into the fornices of the vagina 
and into the vaginal canal. The posterior fornix is especially well packed with a 
long strip of gauze. Then the anterior fornix is packed with another strip. Then 
the upper and middle thirds of the vagina are gently but firmly packed with the 
unused halves of the two long strips. The screw which opens the blades of the spec- 
ulum is then loosened entirely. The dressing forceps press the gauze upward as 
the speculum is being drawn. The speculum is gradually rotated so that the blades 
lie against the lateral walls of the vagina. Thus pressure against the urethra and 
rectum by the separated blades is avoided on removing the bivalve. 



METHODS EMPLOYED IN MEDICAL TREATMENT 



63 



medicament. Powders may be blown into the vagina through 
any of the specula (Fig. 49). 

Volsella, or tenaculum forceps, are used to grasp the anterior 
or posterior lips of the cervix (Fig. 50). If one is applied to either 
lip, it brings the lacerated cervix into a position where we may 
judge whether the red irritated area is a part of the cervical canal 
or whether it is external to the cervical canal and so constitutes 
an erosion. 

The volsella is also occasionally used to grasp the cervix to 
steady it for the introduction of the sound. By pulling on the 
volsella the cervix is drawn down and the fundus is pulled back 
if in anteflexion or forward if in retroflexion, and into a uterus thus 
straightened out the sound may be more readily introduced. 

This instrument is also used to steady the cervix and to lift 




Fig. 49. — Powder-blower, for blowing any desired powders into the vagina, 
which is best done through the Ferguson speculum. As the speculum is slowly 
drawn out, every bit of the exposed cervix and vaginal walls is covered with powder 
in succession. 



it up to permit of the introduction of gauze or Playfair sounds 
or medicated pencils into the uterus and to permit a more thorough 
packing of the posterior fornix with gauze. 

It is of value in pulling down the cervix, when making a bimanual 
examination, to determine the relation of the uterus to a pelvic 
tumor which may belong to the uterus or to the ovary, or which 
may be of an extrauterine nature. 

Tugging on the cervix by a volsella is contraindicated in all 
inflammatory conditions of the adnexa, with peritoneal adhesions 
and with gonorrhea. 

Scarification. — The withdrawal of blood from the cervix and 
uterus by scarification is sometimes indicated in cases of chronic 
fibrosis and congestion of the uterus and in cases where the pre- 
liminary uterine and pelvic congestion, when associated with a 



64 



MEDICAL GYNECOLOGY 



delay in the outflow of the blood, causes intense and excruciating 
pain and colic which lasts until the outflow of blood is established. 
Scarification may be done with the aid of the bivalve or Ferguson 
speculum, the vagina and cervix being thoroughly cleansed. Two 
or three stabs may be made with the scarificator to a depth of 
i cm. Blood up to the amount of one ounce may be withdrawn 




Fig. 50. — Tenaculum forceps of various forms, for grasping the cervix, holding 
it firmly and pulling it down while performing any intrauterine manipulation or 
packing the posterior fornix or while making a bimanual examination. In a bi- 
manual examination it is sometimes of aid to pull the uterus down by a volsella 
and determine its relation to a pelvic tumor. 

from patients who are not anemic. Then a tampon soaked in 
iodoform-glycerin or tannin-glycerin should be introduced, or, 
better still, the upper part of the vagina should be thoroughly 
packed with iodoform gauze. 



INTRAUTERINE THERAPY 

Intrauterine therapy is practised by some, with the use of cot- 
ton rolled in a thin layer on very thin metal applicators ; by others 



METHODS EMPLOYED IN MEDICAL TREATMENT 65 

drugs are introduced into the uterine cavity by the Braun intra- 
uterine syringe (Figs. 51 and 52); and by others the Braun intra- 
uterine syringe is used, covered with cotton, as in the case of the 
intrauterine applicator. 

In making intrauterine injections with a syringe, contraction 
of the uterus may cause uterine colic or may force the fluid into 
the tubes. The cervix, and especially the internal os, must be 




Fig. 51. — Braun intrauterine syringe, for injecting fluids into the uterus. When 
the tip is covered by a layer of cotton, firmly applied, the drug is injected after the 
tip is introduced into the uterus. The cotton becomes impregnated with the solu- 
tion and is evenly applied to the mucosa. No free fluid enters the uterine cavity 
and contractions of the uterus cannot force any fluid into the tubes. The cervical 
canal must be well dilated before using this syringe. The same procedure is applic- 
able to the urethra. 

wide enough to permit of thorough drainage. Hence, in order to 
avoid contraction of the uterus and the forcing of fluid into the 
tubes, it is wiser to use Playfair or other applicators covered with 
cotton and dipped in the desired medicament (Fig. 53). These 
cotton- covered applicators are allowed to remain in the uterus for a 
few seconds. If, however, the internal os is not sufficiently wide, 




Fig. 52. — A modification of the Braun intrauterine syringe, with numerous 
lateral openings at the tip of the cannula. (It can be used in the same manner in 
the urethra.) 

and if the applicator is not quickly introduced, very little of the 
drug comes into contact with the uterine lining. Hence, it is better 
if this method of treatment is desired, to use the Braun syringe 
covered with cotton, the drug being injected only after the syringe 
tip has been introduced into the uterus. The fluid simply moistens 
the cotton and the desired end is attained without danger (Fig. 54). 
The uterus may be treated by introducing into its cavity medi- 



66 



MEDICAL GYNECOLOGY 



cated pencils containing the various drugs in a base of cacao- 
butter, etc. 

Intrauterine applications should rarely be carried out in office 
practice, and if this is to be done they must be preceded by thorough 
dilatation of the cervix. This may be done by incising the cervix 



*3ES£ 



Fig- 53- — Applicators which, when covered with a layer of cotton, and dipped 
into various solutions, are used for making intrauterine applications. When cov- 
ered with a layer of cotton and dipped into sterile vaselin or lysol solution they are 
used to gradually and slowly dilate the cervical canal. 

laterally, up to the internal os, and beginning with intrauterine 
treatment when the incisions are healed. The cervix may be 
gradually dilated by applicators covered with cotton soaked in 
lysol or covered with sterile vaselin and introduced in increasing 
size, after which a thin wick of iodoform gauze is introduced into 




^3<?ssl 



Fig. 54. — Half section showing the method of using the Braun intrauterine syringe. 



the cervix and allowed to remain in place for twenty-four hours, 
being kept in place by vaginal packing. Several treatments of 
this nature are enough to dilate the cervix sufficiently to permit 
of intrauterine applications. 

Another method of dilating the cervix is by the use of sterilized 
tupelo or other tents kept in place for twenty-four hours. Their 



METHODS EMPLOYED IN MEDICAL TREATMENT 67 

action in dilating a cervix is certainly excellent, but they often 
produce extreme pain, so that their use in ambulatory practice 
is not feasible, nor is it advisable. 

The best method, if dilatation must be done in the office, is to use 
the smallest size of uterine sound, then a larger size, leaving each 
in place for a minute. We then continue with Weir's sounds bent 
to the proper curve, using them in succession up to the desired size. 

These methods of dilating the cervix, to permit of intrauterine 
therapy, have little to recommend them. They are dangerous 
if intrauterine therapy is desired for inflammatory conditions of 
the uterus, inflammatory endometritis, uterine leukorrhea, etc. 
We are then dealing with a cervix and a uterus containing micro- 
organisms, and the risk of causing a pericervical inflammation or 




Fig- 55- — Goodell's glove-stretcher dilator, for dilating the cervix. This must 
be used gently, with constant relaxation and rotation of the blades. When used 
vigorously or allowed to slip out while the blades are being separated, it may cause 
deep recognized or unrecognized tears into the cervical wall and into the broad 
ligament. 

lighting up an extension of an intrauterine inflammation is cer- 
tainly present. 

The method of dilating the cervix by sounds or by applicators 
wrapped in cotton and dipped in antiseptic solutions or in sterile 
vaselin, or the introduction of stem pessaries into the cervix, is 
perhaps justified in making the diagnosis of cervical stenosis or 
obstruction as the cause of dysmenorrhea, and in overcoming such 
obstruction when it is considered the cause of dysmenorrhea or 
sterility. It should then be done with the greatest care, and only 
when intrauterine and intracervical infection of any form can be 
absolutely excluded. 

Dilatation of the cervix under anesthesia by dilators of the glove- 
stretcher variety (Fig. 55) or, better still, by the graduated Hegar 
dilators dipped in lysol or sterile vaselin is a necessary preliminary to 



68 MEDICAL GYNECOLOGY 

curettage (Fig. 56). It is also the only proper procedure as a pre- 
liminary step in the hands of those who wish to treat intrauterine 
leukorrhea or intrauterine gonorrhea by intrauterine irrigation 
or by packings with protargol or silver salts, or by irrigation plus 
curettage followed by packing with silver salts. While the value 
of curettage and intrauterine packing in the treatment of uterine 
gonorrhea is a matter to be settled by the future, it at least does 




Fig. 56. — Hegar graduated dilators, for dilating the cervix without the associated 
risk of tearing the cervix. They produce an even dilation. In five to ten minutes 
the cervix can be dilated sufficiently to admit the index or middle finger. 

away with continued irritation and tinkering with an infected 
cervix, which procedure is not infrequently the cause of varying 
degrees of pelvic inflammation. Medicated bougies containing 
iodoform or silver salts or ichthyol, etc., are used by some for 
treating inflammatory conditions of the cervix and uterus. 

Intrauterine Irrigation. — In performing intrauterine irriga- 
tion a double- running catheter of metal should be used. The 




Fig- 57- — Fritsch-Bozeman double-running intrauterine irrigator. It is of 
various calibers. Fluid should be allowed to run out of it before it is introduced 
into the uterus. The cervix must first be dilated. The uterus is irrigated before 
and after curettage. 

anterior half of the Fritsch-Bozeman irrigator (the safest) consists 
of an outer tube with an opening on the under surface of its lower 
end. The tip of the tube is solid, but one-half inch from its tip 
there is on either side a fenestra two inches long. Within this 
outer tube there is a much smaller tube, which by no means fills 
the lumen, and which extends almost to the end of the outer tube 



METHODS EMPLOYED IX MEDICAL TREATMENT 69 

(Fig. 57). The fluid runs in through the inner tube and enters the 
uterus through the lateral fenestra at the anterior end of the outer 
tube. The fluid re-enters these fenestra? and enters the lumen of the 
outer tube and is poured out through the opening on the under sur- 
face of the lower end of the outer tube. By moving the tip of the in- 
trauterine irrigator up and down, all parts of the uterine cavity are 
thoroughly irrigated, and no intrauterine pressure by the injected 
fluid is exerted so long as the opening on the under surface of the 
anterior half remains outside of the cervix. With this instrument, 
of a sufficiently small caliber and of the proper curve, the average 
uterus may be irrigated with small amounts or large amounts 
(reaching up into the quarts) of any desired fluid. Naturally 
enough, this procedure implies a preliminary dilatation of the 
cervical canal, not alone to permit of the introduction of this 
irrigator, but also to permit of ready drainage of the uterus. Such 



© 



Fig. 58. — Small-calibered double-running intrauterine irrigator, for irrigating 
the uterus in office practice (a procedure requiring the greatest care). It is prac- 
tically a modification of the Fritsch irrigator. 

an intrauterine irrigation is done before and after curettage of the 
uterus. In office practice an intrauterine double-running irrigator 
of small caliber and of the form of Fig. 58 is very useful. 

Curet. — The curet finds a legitimate field for use in the removal 
from the uterine cavity of foreign substances, such as placenta, 
or placental remnants, and in the removal of overgrowths of the 
endometrium in the form of polyps or hyperplastic endometrium, 
or overgrown endometrium left behind as decidua after abortion 
in the early stages (Figs. 59 and 60). The symptoms of these con- 
ditions are bleedings, generally of the form of menorrhagia, and, 
in the case of polyps, not infrequently of the form of metrorrhagia. 
Associated with this condition of retention of decidua or placental 
elements, or with the condition of "hyperplastic endometritis," 
is an involvement of the uterine wall. As can be seen from 
the etiology, the uterus is often large, sometimes soft, sometimes 
hard, it is congested, it is subinvoluted. Its contractility is altered, 



7o 



MEDICAL GYNECOLOGY 



and a state of atony often exists. Hence the condition of the 
uterine wall plays an important part in the production of menor- 
rhagia. Curettage not only removes the abnormal endometrium, 
but by its physical stimulus and by the loss of blood rouses the 
uterus to contraction. A curettage, followed as it should be by 
a hot intrauterine irrigation, with a double- running irrigator, of 
lysol 0.5 to i per cent., etc., produces, as can be seen by measuring 




Fig. 59. — Three sharp curets. 

the uterus with a sound, further marked diminution in the size 
of the uterus. The subsequent introduction into the uterine 
cavity of a wick of iodoform gauze, plus the administration of 
ergotol for several days, brings about further involution of the 
uterine wall. In those cases in which the uterus is quite large 
and quite flabby, especially if the cavity of the uterus is large, 
and the walls thin and atonic, atmocausis, carried out for half 
a minute to a minute after the curetting, has a splendid action in 



Fig. 60. — Martin's curet, which is useful in taking out the ring of adenoid tissue so 
often present at the internal os. 



contracting the uterus, and in promoting a serous exudation which 
greatly aids the subsequent involution of the uterus. 

Curettage for hyperplastic endometrium is followed, in the hands 
of many men, by routine applications to the uterine cavity. Per- 
chlorid of iron, carbolic acid, tincture of iodin, tincture of iodin 
and carbolic acid, chromic acid 5 to 10 per cent., chlorid of zinc 
5 to 10 per cent., 50 per cent, carbolic acid in alcohol, ichthyol 
10 to 20 per cent, or stronger, etc., are used as more or less routine 



METHODS EMPLOYED IN MEDICAL TREATMENT 7 1 

procedures. Unless a curetting is too energetically done, or unless 
the subsequent applications exert too deep a caustic action and 
thereby cause atrophy of the uterus or obliteration of the uterine 
cavity, the majority of cases of hyperplastic endometrium treated 
by this method are much improved or cured, so long as a hyper- 
plastic endometrium is really present. 

Frequently, where this condition is diagnosed, there is no hyper- 
trophic endometrium. The uterus is soft and flabby, the walls 
are atonic, and curetting is of no value. Such cases need the 
internal administration of ergot, the use of bimanual massage of 
the uterus, and douches which increase the uteriue tone. Hot 
vaginal douches are of importance in promoting contraction of 
the uterus. Frequently, where a hyperplastic condition is diag- 
nosed, the curet scrapes away very little mucosa, the uterus is 
hard, the curet feels the hard fibrotic walls. We are here dealing 
with alterations of a permanent nature, involving the uterine 
muscle, its connective tissue and vessels. These are the cases in 
which atmocausis carried out for a period of two to five minutes 
sometimes causes marked improvement, but ofttimes only a 
temporary one, so that hysterectomy is often necessary. 

In the treatment of true inflammatory endometritis, of the 
chronic form, there is great difference of opinion as to the use of 
the curet. Some advise against its use, while others report ex- 
cellent results. Although periuterine or adnexal involvements 
constitute a contraindication, yet the curet is used by some even 
in cases complicated by old inflammatory involvements about 
the uterus. In the case of gonorrhea of the uterus only, Boldt 
and many others advise curettage followed by intrauterine applica- 
tions or by intrauterine packings soaked in germicidal solutions, 
usually the silver salts. It must be remembered that gonorrhea 
involving the uterus is a disease the extent of which cannot be 
accurately gaged. In many cases the condition is a superficial 
one, as Bumm believes it to be in the vast majority of instances. 
The reaction of individuals to the inroads of the gonococcus is 
most variable. In some the disease produces marked rapid exten- 
sion and deep subepithelial involvement, the activity of the process 
continuing for months and years. In others the condition is not 
extensive nor is the involvement deep, and these patients seem 



72 MEDICAL GYNECOLOGY 

relatively immune, in the sense that they more or less readily 
overcome the infection and the gonococci disappear. In consider- 
ing the treatment of intrauterine gonorrhea, we may divide the 
cases into three classes : (i) That form associated with pyosalpinx; 
(2) a form associated with mild salpingo-oophoritis, of which 
sterility is often the only symptom. (3) The third class is that in 
which neither subjectively nor objectively can involvement of the 
adnexa be determined. It is difficult to see the value of curettage 
in the first class of cases, and the dangers associated with the use 
of the curet in the presence of pyosalpinx are not to be under- 
estimated. In the second class, where marked peritoneal involve- 
ment is often absent, the danger of lighting up a recrudescence is 
certainly great. In the third class, where we presuppose no disease 
of the tubes, ovaries, or peritoneum, why take the chance of pro- 
ducing such a disease, with the resulting consequences of sterility 
and pain? In those cases in which the condition is limited to 
the uterus, and is superficial, there is a relative immunity on the 
part of the patient, and conservative treatment aids the natural 
resistance of the patient in ridding the mucosa of the superficial 
changes. At best this condition is no bar to pregnancy, for this 
takes place in many cases. Care and conservative treatment 
have not infrequently resulted in pregnancy even when a gonorrhea 
has involved the tubes, ovaries, and peritoneum. There are cases 
of intrauterine gonorrhea in which no intrauterine therapy will 
rid this organ of its specific diplococci. The experience of Bumnr 
shows that even his method not rarely results in a disappearance 
of the gonococci, only to be followed subsequently by their reap- 
pearance. The annoyances which patients suffer as a result of 
localized intrauterine gonorrhea are not sufficient of themselves 
to justify the use of the curet, and if associated lesions of the tube, 
ovary, and peritoneum are the factors which bring the patient to 
us for help, in my opinion curettage is certainly not indicated 
then. 

In the treatment of uterine conditions of uncertain etiology 
associated with pathologic discharge, we must recognize some as 
due to gonococci, but without the microscopic evidences of their 
presence; we may consider some of them as originally gonorrheal, 
and eventually chronic, as a result of structural changes and the 



METHODS EMPLOYED IN MEDICAL TREATMENT 73 

presence perhaps of other bacteria and cocci. Some we may 
consider as originally due to other bacteria than the gonococci. 
This is an all-important question. Either there once existed a 
mild or severe inflammatory endometritis after abortion or labor, 
which persists in subacute chronic form, or else there has occurred, 
in a uterus congested and hyperemic, an invasion of non-specific 
bacteria which produce and keep up a more or less constant 
intrauterine discharge. It is often impossible to distinguish such 
cases from the forms of hypersecretion existing in uteri subjected 
to the alterations of subinvolution and the hypersecretion associated 
with chlorosis and anemia, or associated with the congested uteri 
of fat women, many of whom are multiparae. 

In these various forms the curet in the hands of many is used 
because of the uterine leukorrhea, and often, as reports go, with 
very satisfactory results. By others intrauterine applications 
without curettage are applied : chromic acid, 5 per cent. ; perchlorid 
of iron, 5 per cent.; sulphate of zinc, 5 to 10 per cent.; chlorid of 
zinc, 5 to 10 per cent.; carbolic acid and alcohol, equal parts; 
ichthyol, 10 to 20 per cent.; tincture of iodin, 50 per cent.; nitrate 
of silver, 5 per cent., etc. I never use the curet for uterine leukor- 
rhea alone. 

It is in this class of cases, if the annoyances justify its use, that 
intrauterine irrigations are applicable. The solutions used with 
the aid of the double- running irrigator are numerous. 

In this class of cases the safest and most conservative treatment 
is the use of prolonged cold water vaginal douches. 

Much is considered, however, under endometritis which has 
nothing to do with inflammation of the endometrium. 

Leukorrhea in anemic and chlorotic girls is originally due to 
anemia of the mucosa, and to subsequent serous transudation, on 
the part of the hydremic blood. On this basis, of course, there 
occurs more readily an inflammatory endometritis. 

Isolated inflammation of the cervix mucosa is to be treated by 
drugs. Vaginal douches are of value, when cool, in the acute stage, 
and hot in the chronic stage. Mud baths and carbonated saline 
baths are important. When the portio is hyperemic, in addition to 
the bath treatment Glauber's salts are of value. If hyperemia per- 
sists, we use cool douches of 70 to 55 . Scarification followed 



74 



MEDICAL GYNECOLOGY 



by suction can be carried out. The treatment of erosions is by 
medicaments. 

Curettage. — In the performance of curettage all the aseptic 
precautions of a major operation should be observed. The 
vulva should be shaved and thoroughly disinfected, and the vagina 

should be scrubbed 
with green soap with 
the aid of a gauze 
sponge on a sponge- 
holder, followed by a 
thorough scrubbing 
with 0.5 to 1 percent, 
lysol solution. 

The patient is in 
the lithotomy position 
on a Kelly pad. The 
entire vulvar area is 
covered with a sterile 
sheet, with the excep- 
tion of an opening 
large enough to per- 
mit of the required 
manipulations. A 
towel or the lower 
margin of the perfor- 
ation in the sheet 
should be fastened by 
a suture to the peri- 
neum so that the anus 
is entirely out of the 
field. A Garrigues 
weighted speculum, 
which is self- retaining, or an Edebohls speculum to which is at- 
tached a small pail to catch the fluids, and which is likewise self- 
retaining, may be used. 

With proper assistance, however, a broad flat speculum is 
better, and should be held in place by an assistant. An 
anterior speculum is introduced so that the cervix is brought 




Fig. 61. 



-a, Anterior vaginal retractor; b, posterior 
vaginal retractor. 



METHODS EMPLOYED IN MEDICAL TREATMENT 



75 



into view, and the anterior lip of the cervix is then grasped firmly 
with a volsella. The cervix is dried and a sound is introduced 
to measure the length and position of the uterus. The cervix 
must then be thoroughly dilated. This may be done with the 
glove-stretcher dilator, or, better still, with Hegar graduated 
dilators, which are dipped into a lysol solution or into sterile 
vaselin. With the 
latter dilators, if 
time is taken, a 
very thorough dila- 
tation of the cervix 
is obtained with- 
out breaking the 
tissues, and the 
danger of tearing 
through the cervix 
into one or the 
other of the broad 
ligaments is obvi- 
ated. This danger 
is always present 
when using a glove- 
stretcher dilator 
hastily with a rigid 
cervix. 

Figs. 6 1 to 64 
show flat vaginal 
specula, of var- 
ious lengths and 
breadths, to be 
used as anterior 
and posterior re- 
tractors in manipulations or operations on the cervix and uterus. 
They are of great aid in performing vaginal celiotomy. 

After thorough dilatation of the cervix the uterus is irrigated 
with a 0.5 per cent, solution of lysol (Fig. 65). A small sized curet 
is taken and the index-finger of the right hand is placed at a distance 
from the tip which corresponds to the length of the uterus as 




Fig. 62. — a, Wide vaginal speculum; b, narrow vaginal 
speculum and retractor. 



7 6 



MEDICAL GYNECOLOGY 



measured by the sound. If the finger be held at this point during 
the performance of curettage, the danger of perforating the uterus 
is out of the question (Fig. 66). The inner surface of the uterus is 
then curetted by gentle but firm movements from above downward, 
passing around the entire interior of the uterus in succession. 
This manipulation is repeated two or three times, particular at- 





Fig. 63. — Simon's posterior vaginal 
speculum. 



Fig. 64. — Anterior vaginal retractor. 



tention being paid to the lateral borders of the uterine cavity and 
to the region of the uterine cornua. 

When the curet has removed the superfluous tissues and sufficient 
of the endometrium, its contact with the uterine wall causes a 
feeling of resistance and produces a hard, gristly sound. The 
uterus is then again irrigated with a double- running catheter, 
0.5 to 1 per cent, lysol solution being used. 



METHODS EMPLOYED IN MEDICAL TREATMENT 77 

A smaller curet is again introduced and the surface is gone over 
again gently and the uterus once more irrigated; a twisted wick 
of iodoform gauze is then introduced into the uterus by the intra- 
uterine packer and withdrawn so that the uterus is freed of the 
retained fluid or blood. A fresh twisted strip of iodoform gauze 
is then packed again into the uterus, and especially into the cervix, 
and an end long enough to reach beyond the vulva is held outside 




Fig. 65. — Half section, Fritsch intrauterine double-running irrigator in place. 
So long as the opening on the under surface is outside of the cervix no great intra- 
uterine pressure by fluid can be exerted. 

the vulva (Fig. 67). The volsella which grasps the cervix is 
taken off and a wide strip of iodoform gauze is then packed 
thoroughly into the fornices and in the vagina, passing in circular 
fashion about this intrauterine strip. The speculum is then 
removed and a knot is tied in the intrauterine strip so that it may 
be recognized and removed after twenty-four, forty-eight, or 
seventy-two hours without disturbing the vaginal packing. 

So soon as possible ergot, or better ergotol (15 minims), is 



78 



MEDICAL GYNECOLOGY 



administered every three hours for several days, even after the 
removal of the intrauterine strip. 

The vaginal packing is removed after three or four days, and 
short hot vaginal douches containing lysol 0.5 per cent., or carbolic 
acid 1 per cent., or bichlorid of mercury 1 : 5000, are given. 




Fig. 66. — Half section of the pelvis, showing posterior retractor and volsella 
in place with the curet in the uterus and the finger held on the curet to avoid danger 
of perforation. In curettage the index-finger of the right hand, when placed at a 
measured point on the curet, and held there during the curetting, avoids the danger 
of entering so deeply with this instrument as to perforate a uterus. The length of 
the uterine canal is first measured with a sound, most gently introduced, and the 
finger is placed on the curet at the corresponding point. 

The operation of simple curettage can be very well performed 
with the aid of nitrous oxid anesthesia. If curettage is done for 
incomplete abortion in the very early weeks, this method suffices, 
very great care being necessary to use a medium-sized curet with 
the gentlest of manipulations. The size of the uterus must be 
determined by bimanual examination and by the use of the sound. 



METHODS EMPLOYED IN MEDICAL TREATMENT 79 

In progressing abortion in the third or fourth months with the 
retention of the ovum, if the cervix is very well dilated the uterine 
contents may often be removed by the careful use of the placental 
forceps (Fig. 68). If the cervix is not well dilated, it may be 
stretched either by the glove- stretcher dilator, or, better still, by the 
use of the Hegar dilators. On the other hand, it is wise, unless 




Fig. 67. — A wick of iodoform gauze is introduced into the uterus by the dressing 
forceps or, better still, by a packer which is of the caliber of a sound and which has 
a serrated tip so that the end of the gauze, when placed on it, does not slip off. 

the surroundings and conditions prevent, to dilate the cervix in 
most of these cases by packing the uterus, and especially the cer- 
vix, under strictest aseptic precautions, with iodoform gauze, and 
then packing the fornices and vagina to the introitus vaginae with 
a wide strip of iodoform gauze. This method of painless dilatation 
of the cervix has the advantage that no injury is done to the friable 
cervical tissues. 



8o 



MEDICAL GYNECOLOGY 



It happens often 



Fig. 68.— Placen- 
tal forceps, to be in- 
troduced into the 
uterus to grasp an 
ovum, or fetal sac or 
retained products of 
conception which are 
lying in the uterine 
cavity. If it is de- 
sired to remove pla- 
cental tissue in con- 
tact with the uterine 
wall, the location of 
this tissue should be 
first determined by 
introducing the mid- 
dle finger into the 
uterus. One blade 
of the placental for- 
ceps serves well as a 
dull curet. 



enough that the retained ovum is found readily 
by the placental forceps 
after this method of dilata- 
tion, especially if during 
the time in which the gauze 
has been in place (twenty- 
four to forty-eight hours) 
ergot or ergotol is admin- 
istered. The administra- 
tion of ergot causes contrac- 
tion of the uterus, and, the 
exit of blood being pre- 
vented by the gauze, the 
ovum is loosened from con- 
tact with the uterine wall. 
After removing the gauze 
the placental forceps may 
grasp the ovum and remove 
it in toto, even without the 
use of anesthesia. Careful 
curettage with a blunt curet 
(Fig. 69) completes the oper- 
ation and is followed by an 
intrauterine irrigation with 
very hot lysol (0.5 per cent.) ; 
temperature, 1 1 5 F. If the 
uterus does not contract 
well, 4 ounces of dilute 
acetic acid to the quart of 
hot water is used as an in- 
trauterine irrigation. The 
uterus is then packed with iodoform gauze and 
so is the vagina. 

Curage in Abortion in Third and Fourth 
Months. — If the placental forceps do not grasp 
a loosened ovum, the middle finger, under the 
strictest aseptic precautions, is introduced into 
the cervix and uterus ; the other hand, pressing 



Fig. 69. — Dull 
curet, for removing 
placental tissue in 
contact with the uter- 
ine wall and for re- 
moving decidual tis- 
sue by very gentle 
curettage. 



METHODS EMPLOYED IN MEDICAL TREATMENT 8 1 

through the abdominal wall, pushes the uterus down into the pelvis, 
and pressing on the fundus brings it in contact with the internal fin- 
ger. In this way the middle ringer of the internal hand can palpate the 
entire uterine cavity, can separate the whole ovum or the adherent 
parts, or remove whatever of fetal sac or placenta is attached (Fig. 
70) . After this procedure the placental forceps carefully introduced 
can extract whatever loosened contents are in the uterus. The uterus 
should then receive a very hot douche, with a double- ruuning 




Fig. 70. — Half section, showing the introduction of the middle finger into the 
uterus and the pressing down of the fundus uteri by the external fingers. By this 
combined manipulation an ovum can be completely loosened from connection with 
the uterine wall and adherent placental tissue can be scraped off. This method, 
known as " curage," is a sure, safe procedure and obviates the danger of perforation 
or of leaving behind unrecognized fetal products. The cervix must be well dilated. 

irrigator, of i per cent, lysol. If the finger has been unable to 
separate part of the placental tissues, their location at least is noted, 
and placental forceps or a large blunt curet are then introduced for 
their removal. The uterus is then packed with iodoform gauze and 
ergot is administered. The vagina is also packed with iodoform 
gauze. The gauze is removed in from twenty-four to forty-eight 
hours and the ergot is continued. In incomplete abortion it is 
rarely necessary to use the sharp curet unless, in very early cases, 
the uterus is so small that the finger method, or curage, cannot be 
6 



82 MEDICAL GYNECOLOGY 

used. The use of the sharp curet alone is a dangerous thing in 
abortion in the third and fourth months : First, we are never sure 
that we have removed all the products of conception; second, 
perforation of the uterus occurs very readily. During the manipu- 
lation of the curet the uterus dilates and contracts easily, as it 
does in the post-partum period at full term, and if the curet is 
held very firmly, simple contraction of the uterus is enough to 
cause perforation by this instrument, even if dull. 

It is by no means infrequent to find in abortions at the tenth 
or twelfth week, when an embryo is spontaneously expelled, that 
decidua, the sac of the ovum, or placental remnants are retained. 
These, as a rule, prevent the uterus from returning to normal size, 
the cervix does not contract, and there is generally a steady or 
irregular loss of blood. Under these circumstances the method 
of slow dilatation of the cervix by packing it and the vagina with 
iodoform gauze for twenty-four hours, and of examination and 
cleansing of cavity with the finger, is advisable. If this pro- 
cedure is not possible, or if the finger finds no retained fetal tis- 
sues, the dull curet should be used with the greatest of precaution. 
In using any curet in the uterus, it is my custom to first measure 
the length of the uterine cavity with a sound and then to place the 
index-finger of the right hand on the curet at a point which makes 
the distance from the tip of the curet to the finger a little less than 
the length of the uterine canal, as measured by the sound. Curet- 
tage is then done, with the finger held firmly on this point, so that 
the instrument at no time enters further into the uterus than 
the measured length. The above described method of painless, 
slow dilatation of the cervix by the use of iodoform gauze is the 
safest and wisest procedure. The above method of removing 
the contents of the uterus by the introduced finger is surest and 
safest. The finger recognizes adherent tissues. It locates any 
tissue that cannot be scraped off; it cannot perforate the uterus. 
It makes the diagnosis and carries out the treatment. It should be 
used in every case in which the uterus is three times the normal 
size. 

Atmocausis. — Snegirjeff, in Moscow, has for years used steam 
at a temperature of ioo° C. in controlling uterine bleedings. 
In his opinion, steam cauterizes, stops hemorrhage, removes 



METHODS EMPLOYED IN MEDICAL TREATMENT 83 

every odor, and diminishes the sensitiveness of the inner lining of 
the uterus. 

Pincus introduced this method into Germany. His first ex- 
perience was with an inoperable corpus carcinoma, with endo- 
metritis hyperplastica, and with endometritis cervicis, obtaining 
good results. Since then the method has been used on many 
sides and for quite a series of gynecologic affections. Kahn used 
this procedure in many cases of septic post-partum endometritis 
with very quick benefit. He found that the sensitiveness of the 
uterus is diminished and that good contractions result. The steam 
has a bactericidal effect and the disagreeable odor disappears. 
Through thrombosis, the blood-vessels and lymph-vessels are 
closed and a protecting cover is formed for the development of 
fresh granulations. Clinically, temperature falls, usually by 
crisis. Only in those cases where action is delayed, or where 
placenta or membranes are retained, does an immediate improve- 
ment fail to result. Pincus obtained good results in putrid abor- 
tions, in climacteric hemorrhages where abrasio failed, in sub- 
involutio uteri and gonorrheal infections. In the clinic of Paw- 
lik, in Prague, about fifty cases were first treated by this method, 
and with excellent results, especially cases of abortion with profuse 
bleedings due to atonic uteri, and chronic hemorrhagic endome- 
tritis. 

The improvements which Duhrssen made in the apparatus 
used for this purpose are undoubtedly responsible, in a great 
measure, for the good results. Originally, Pincus used metallic 
catheters for the intrauterine introduction of steam. Later he 
added a tube which permitted the outflow of the liquefied steam. 
Since the metal tubes caused deep cauterization and stenosis of 
the cervix, through direct contact of the hot catheter, he used 
gauze to protect this part of the uterus. Later he used tubular 
wooden plates to protect the lining of the cervix from cauterization. 

Unfavorable results were reported, among others by Czempin, 
who mentioned an atrophia uteri with climacterium praecox in a 
patient who, six and one-half months post partum, was treated 
by this method for a hemorrhage lasting eight weeks. A death 
was reported from the clinic of Traube, due to necrosis and per- 
foration of the uterus resulting in peritonitis. Von Weiss recorded 



8 4 



MEDICAL GYNECOLOGY 



an obliteratio uteri in a non-puerperal case treated for continued 
uterine bleeding. 

These failures and poor results occurred for the following 
reasons : 

i. The introduced catheter permitted no outlet for the vapor, 
so that a continued action of the same resulted. 

2. The heated metal catheter caused a deep cauterization, 
through direct contact with the cervix and uterus. 

3. On contraction of the uterus the tip of the metal catheter 

exerted a local 
and deeply cau- 
terizing action. 

The advan- 
tages of the 
apparatus of 
Duhrssen (Figs. 
71 and 72) are 
as follows : 

1. The uterine 
tube consists of 
fiber stuff which 
does not trans- 
mit heat, so that 
the cervix is pro- 
tected. 

2. This tube is 
centrally perfor- 
ated and its lu- 
men is so large that when the metal tube through which the steam 
enters the uterus is introduced there is sufficient room for an out- 
flow of steam and coagulated blood (Fig. 72). 

3. This metal tube, through which the steam passes, does not 
come in contact at any point with the mucous lining of the uterus. 

I have used this method mostly for bleedings which cannot 
be overcome by other methods. Frequent cases are climacteric 
bleedings, where our purpose is to cause a destruction of the 
endometrium with resulting obliteratio cavi. At the same time 
the future development of a corpus carcinoma in such cases is 




Fig. 71. — Atmocausis boiler for the production of steam 
"which is to be introduced into the uterus for periods vary- 
ing from thirty seconds to seven minutes (atmocausis). 
The cervix must first be well dilated and the uterine lin- 
ing must be free of fetal products or of new-growths. This 
method is used for uterine bleedings. 



METHODS EMPLOYED IN MEDICAL TREATMENT 85 

rendered impossible. A dilatation of the cervix is a preliminary 
in all cases, not alone to permit of easy introduction of the uterine 
tube and to furnish subsequently good drainage, but also often to 
permit of tactile examination in continued bleedings. In spite of 
the good results obtained by this method in some patients, I have 
been compelled several times to perform a hysterectomia uteri. 

' It should be known that vaporization is used for a number of 
gynecologic affections, in addition to uterine bleedings due to metro- 
endometrial changes and to climacteric local processes. Pincus 
and others use this method in quite an extended class of cases. 
For ordinary use the duration of vaporization is thirty to forty 
seconds; for obliteration, five minutes or more at a temperature 
of ioo° to iio°C. Pincus finds as indications for this method 
the following forms of affection : Endometritis, especially hemor- 
rhagic and gonorrheal; incipient puerperal endometritis; uterine 
atony; bleeding due to interstitial myoma; subinvolution; as a 
preliminary to hysterectomy; as a palliative in inoperable car- 
cinoma; in putrid abortion. To this treatment of the last-men- 
tioned affection decided objection has been raised on many sides. 
In addition, the method is used by Pincus very frequently in the 
treatment of climacteric bleedings and senile catarrh, in both of 
which cases an obliteration of the uterine cavity is desired. He 
finds the contraindications to be malignant growths of the uterus, 
tumor conditions of the tubes, and adnexal abscesses. 

The limits and absolute indications for this method are not clearly 
defined. The accepted indications for me are those followed by 
Fehling, who also obtained good results in bleedings due to en- 
dometrial changes, and in climacteric bleedings. He, however, on 
the fourth to sixth day after curettage, atmocauterized for five to 
twenty seconds at a temperature of no° to 115 C. As said be- 
fore, I use this method frequently for uterine subinvolution, gener- 
ally for uterine bleedings not controlled by the curet or by local 
treatment. 

The procedure in treating bleedings with this method is as follows : 
A positive diagnosis of the condition at hand must be made in all 
cases. Dilatation of the cervix is an all-important preliminary 
for many reasons. It permits examination of the uterine cavity 
with the finger if desired. If no local changes are present, and if 



86 MEDICAL GYNECOLOGY 

there is no retention of fetal membranes, not infrequently vaporiza- 
tion suffices without previous curettage. Retained membranes 
and malignant changes must be excluded before using this method. 
Only the finger can prove absolutely that the uterus is empty, 
and only curettage, aided by examination with the finger, makes 
it certain that we have removed those portions of the endometrium 
which are abnormal, and which are to be examined for malignant 
changes. In addition, dilatation of the cervix changes the three- 
cornered uterus into a circular canal, so that subsequent use of 
steam affects all parts of its lining equally. In addition, dilatation 
of the cervix permits of the use of a large uterine tube, so that 
when the metal catheter, through which the steam passes, is 
introduced, there is sufficient room in the uterine tube for the exit 
of the liquefied steam and coagulated blood and serum. Lastly, 
and equally important, is the fact that a dilated cervix, permits 
of a readier natural drainage of the uterus during the subsequent 
period. A necessary preliminary, then, not alone for the sake 
of a positive diagnosis, but for the other reasons mentioned, is 
dilatation of the cervix, for which packings with iodoform gauze 
or dilators are used. In simple cases with dilated cervix narcosis 
is unnecessary, since the uterus loses its sensitiveness on the 
contact of steam. It is only when this is applied to the cervix 
that some pain is experienced. As a rule, the cervix must not be 
treated, for atresia is possible before obliteration of the uterine 
canal in those cases where obliteration is desired. If, however, 
the cervix is likewise vaporized, in such cases attention must be 
paid to the prevention of too early atresia. On the introduction 
of two vaginal specula, after disinfection of the vagina and cervix 
with lysol, the anterior lip of the cervix is grasped with volsella. 
The uterine tube, having been previously boiled, is then in- 
troduced in the cervix. This tube is marked so that it can 
be easily determined how far it has been introduced. If the 
entire uterine cavity is to be treated for only a few seconds, 
the uterine tube is introduced as far as the internal os. If the 
entire uterine cavity is to be treated for several minutes with the 
purpose of obliterating it, the uterine tube, after previous measure- 
ment of the uterus with the sound, is introduced to within 2 cm. 
of the fundus, the markings on the uterine tube permitting this 



METHODS EMPLOYED IN MEDICAL TREATMENT 



87 



to be done with exactness. The metal tube which carries the 
steam is then introduced, a bulb at its lower end closing the opening 
at the external end of the uterine tube (Fig. 72). During the 
process of treatment this inner metal catheter is moved occasionally 
to permit the outflow of liquefied steam and coagulated blood, 
and to prevent too high pressure in the uterus. Shortly after 
contact of the steam the uterus contracts, and during the following 
minutes the uterine tube is slowly and gradually drawn out, until, 
when it reaches the internal os, the entire inner surface of the 
uterus has been affected. If desired, the tube is drawn out up 

to the external os, whereby action on 

the lining of the cervix likewise takes 

place. The inner metal catheter does 

not extend fully up to the end of 

the uterine tube, so that at 

no time is it in contact 

with the uterus or cervix. 

The uterine tube, 




Fig. 72. — Section showing atmocausis tubes in place. The space between the 
inner and outer tubes is to be noted. Little knobs on the inner tube carry the 
altered blood down and out as this inner metal tube is drawn out slightly at regular 
intervals. This method is valuable for uterine bleedings, especially climacteric 
bleedings, when malignancy has been excluded by tactile examination and by ex- 
amination of the scrapings. 



being made of fiber stuff and transmitting no heat, protects the 
cervix fully from contact with the heated metal inner tube. After 
treatment, rest in bed for ten to fourteen days is necessary; no 
irrigations being given except a vaginal irrigation after several 
days, if a large serous flow makes the patient uncomfortable. 

The duration of the application of steam is, as a rule, thirty 
to forty seconds in younger women, where no obliteration is 
desired; five to eight minutes if total obliteration is intended. 
The temperature used is ioo° C. in the boiler of the instrument, 
which temperature is there registered by a thermometer. The 



88 MEDICAL GYNECOLOGY 

boiler of the instrument is protected by a safety-valve, which elimi- 
nates all danger, for the outlet tube is controlled by a stop-cock 
for two purposes : first, it may be desired to use steam of a higher 
temperature, which can readily be obtained if the stop-cock is 
closed; second, before introducing the metal catheter conveying 
the steam into the uterine tubes, the stop-cock is opened to see 
if the steam appears and to remove from the metal catheter any 
water. The stop-cock is then closed for a second or two until the 
catheter is introduced into the uterine tube. At any time, if de- 
sired, the supply of steam may thereby be shut off. (See Fig. 71.) 
It has been found experimentally that the steam when it enters 
the uterus is probably of a temperature of about 70 C, if the 
thermometer in the boiler registers ioo°. Whether this be true 
or not, continued practice wtih this apparatus has shown that the 
above-named limits are absolute. There is generally a serous 
discharge for days or weeks after this treatment. The action 
upon the uterus and its lining may be judged by the character 
of the necrotic tissue which is thrown off in bits or as a whole. 
This necrotic tissue makes its appearance in from six to ten days 
if the action has been superficial, and in ten or more days if a 
deeper cauterization has resulted. If this method is to be repeated, 
it should be done only after a lapse of four weeks, when the mucous 
lining has been regenerated. Not infrequently, after this treat- 
ment, irregular bleedings or one or two increased menstrual 
bleedings may occur. The former are the result of the throwing 
off of necrotic tissue; the latter gradually go over into natural 
menstruation. The action of this method in causing involution 
may be seen from the fact that in a case of metritis fibrosa, with 
a uterine cavity 12 cm. in length, six months after vaporization 
the uterine cavity measured 6 cm. This patient had been curetted 
twice, had been treated with local applications of iodin, and with 
numerous internal remedies. The contraindications to the use 
of this method are malignant changes of the endometrium and the 
presence of retained placenta or membranes. Other contraindica- 
tions are those affections of the tubes and those inflammatory condi- 
tions which are generally recognized as contraindications to curet- 
tage. While the value of atmocausis in other conditions is still a 
question of personal experience, there is no doubt that uterine 



METHODS EMPLOYED IN MEDICAL TREATMENT 89 

bleedings, especially the bleedings of climacterium and the uncon- 
trollable hemorrhages occurring at this period and in earlier periods, 
are positive indications for its use, especially when curettage and 
other local methods are of no avail. Since my experience and the 
investigations of others have proved a large proportion of such 
cases to be due to degenerative changes in the uterine muscula- 
ture, I may say that atmocausis, if not a specific, is at least the 
best method of treatment for uterine fibrosis and arteriosclerosis. 
If this fails, hysterectomy is indicated. 

PESSARIES 

A Smith or Hodge or Thomas pessary (Fig. 73) meets the in- 
dications for the correction of retroversion, retroflexion, and retro- 
displacement and for the support of hysteroptosis without retro- 
deviation. 

The shape of each pessary, as to its length and the degree of 
its curt, should be fitted according to the character and size of 






a 

c 
Fig. 73. — a, Hodge pessary; b, Smith pessary; c, Thomas pessary. 

the vagina. Rubber rings of different sizes may be put in boiling 
water and then bent into proper form for those cases where the 
ready-made pessary does not meet the indications (Fig. 74). In 
fitting a pessary its length should correspond to the distance from 
the symphysis to the posterior vaginal fornix as measured by the 
fingers when the uterus has been replaced and the cervix has 
been pushed far back and high up. The width of the pessary 
at its posterior end must be sufficient to fill out the posterior fornix; 



9° 



MEDICAL GYNECOLOGY 



the upward curve of the posterior bar should be high enough to 
bring the posterior end high up back of the cervix. The anterior 




b c 

Fig. 74. — a, Ring to be placed in boiling water and made into any form of pessary, 

as b, c, d, 



end should not be too wide, just wide enough to fit behind the 
symphysis, and to be supported and kept in place by the symphysis. 

The anterior curve should 
be marked enough so that 
the tip does not press 
against the urethra. The 
anterior bar may be in- 
dented so as to form an 
arch over the urethra. 

It requires patience 
and frequent attempts to 
get the right form and 
size for many cases. A 
wise rule is that of always 
using the smallest possi- 
ble size first, rather than 
taking the chance of 
introducing a pessary 
which is too large. 

The pessary is sup- 
posed to be held by the levator ani muscles and by the elastic 
pressure of the vaginal wall. It must not be permitted to press on 
any bony prominence. It should cause no pain. 

The pessary when in place acts by stretching the posterior 




Fig. 75. — Drawing showing various positions 
of the uterus, anteflexion, retroversion, retroflex- 
ion, with the changed position of the cervix, 
which has moved down and forward in the two 
latter. 



METHODS EMPLOYED IN MEDICAL TREATMENT 



9 1 



fornix, by keeping it high up and far back, and so carrying the 
cervix with it. When properly fitting, a pessary gives no pain or 
annoyance. Adhesions about the uterus or inflammation of the 
adnexa are contraindications to the use of the pessary. In long- 
standing retroflexions or in retrodisplacements where the utero- 
sacral ligaments are firm and contracted, preliminary treatment 
in the form of massage or intravaginal pressure therapy may be 
necessary to enable us to lift the cervix up and backward so that 
the fundus will naturally fall forward. In other cases treatment 
by glycerin and gauze is often advisable to first permit of a return 




Fig. 76. — First step in the correction of mobile retroflexion. The internal fingers 
are introduced under and back of the cervix to lift it up. 



of the subinvoluted, stretched ligaments of the uterus to their 
normal elasticity. In those cases where replacement is difficult 
in spite of the absence of adhesions, gauze soaked in glycerin, 
packed thoroughly into the posterior fornix while the cervix is 
pulled down by a volsella, is made use of on several alternate 
days, and will aid the subsequent ready reposition of the uterus. 

Replacing the Uterus. — Without the aid of the external hand, 
the internal fingers should be passed deeply into the posterior 
fornix and underneath the cervix, and the fundus and cervix 
should be lifted up toward the abdominal wall (Fig. 76). This 
puts the uterosacral ligaments and the posterior parametrium on 



9 2 



MEDICAL GYNECOLOGY 



the stretch. If then the middle ringer be passed from right to 
left in the posterior fornix, thickened uterosacral ligaments can 
be made out and any peritoneal adhesions on the posterior wall 
of the uterus can be felt. At the same time the mobility of the 
uterus is defined, and pain will be produced in the back and in 
the rectum in pathologic involvements of the posterior parametrium 
and greater pain with peritoneal adhesions. The fundus should 
then be pushed upward (Fig. 77). After performing this manipu- 
lation the index-finger should be placed in the anterior fornix 
and the middle finger high up in the posterior fornix (Fig. 78) . The 




Fig. 77. — Second step in the correction of mobile retroflexion. The internal 
fingers pass high up into the posterior fornix and push the fundus of the uterus up- 
ward. If the fundus can be carried as high as pictured here, the external finger 
may pass behind it. This is rarely possible. 



index-finger then pushes the cervix down and backward, which 
manipulation, when repeated several times with increasing firmness, 
always preceded by the lifting of the cervix, will bring a mov- 
able fundus further forward, away from the sacral promontory 
(Fig. 79), especially if the internal fingers at the beginning pushed 
the fundus upward (Fig. 77). If then (Fig. 79) the external hand 
be pressed down through the abdominal wall toward the hollow of 
the sacrum, behind the point to which the fundus is brought by 
this manipulation, and if then these fingers pull or massage the 



METHODS EMPLOYED IN MEDICAL TREATMENT 



93 



fundus toward the symphysis (Fig. 80), almost every case of 
movable retroversion and retroflexion can be brought temporarily 
into normal anteversion or anteflexion. If the external fingers 
be passed behind the uterus and the uterus cannot be brought 
forward or can be brought forward only with pain, we may pre- 
suppose the existence of peritoneal adhesions to the uterus, or 
fixation of the tubes and ovaries with shortening of the ligamenta 
infundibulopelvica, or else we feel the retracted uterosacral liga- 
ments. In such instances the two fingers of the internal hand 
being passed high up into the posterior fornix can make out the 
peritoneal adhesions, and if passed into the lateral fornices can 
make out the lateral or deep fixation of the tubes and ovaries. 




Fig. 78. — Third step in the correction of retroflexion. The index-finger in the 
anterior fornix is to push the cervix downward, backward, and upward, and thus 
influence the fundus to move upward. 

Introducing the Pessary. — In introducing the pessary the 
uterus should first be replaced and the cervix pushed back and 
up with the fingers of the internal hand. The pessary should be 
well oiled with vaselin or soapsuds. The pessary is then intro- 
duced over the palmar surface of the fingers which are in the 
vagina (Fig. 81). It is introduced in a position midway be- 
tween the transverse and the longitudinal diameter of the vagina, 
the posterior bar passing into the anterior fornix. The internal 
fingers then pass through the posterior curve and back over 
the broad bar of the pessary, and the fingers are turned so that 



94 



MEDICAL GYNECOLOGY 



the palmar surface looks down. This manipulation by the fingers 
gradually carries the pessary into the transverse position and car- 
ries it backward toward the posterior fornix (Fig. 83). The 
anterior end is held by the index-finger of the other hand so 
that it does not press against the urethra and the symphysis, and 
then the posterior end is depressed under the cervix so that 
it slips up behind it. The anterior end should disappear behind 
the symphysis (Fig. 84). The patient is told to press or bear 




Fig. 79. — Fourth step in the correction of retroflexion. . The index-finger in the 
anterior fornix has pushed the cervix down, back, and upward. This step, re- 
peated several times with increasing force, has caught the fundus at the correct 
elevation and it moves upward and forward. The firmer the area at the internal 
os, the more readily is this manipulation carried on. 



down as if at stool, and if the pessary is properly fitted it will 
remain in place and the anterior end will be only slightly visible. 
If too long, a shorter pessary should be used. If the anterior 
end is too wide, a narrower one should be selected. The pessary 
is of especial value in post-partum treatment to prevent the 
development of an acquired retroversion or retroflexion. In 
long-standing instances, where operation is refused, it may be 
worn for years if the patient takes douches daily, and if the 
pessary is removed, cleansed, and replaced at least once a month. 



METHODS EMPLOYED IN MEDICAL TREATMENT 95 

In some of these cases it may effect a cure of a long existing 
retrodeviation, but this result is uncertain and occurs only in 
a small percentage of cases (10 to 15 per cent.). 

In displacements, in descent, and in prolapse the pessary fits 
between the uterus and the levator ani. The pessary stretches 
the posterior fornix and pushes the cervix high up and backward. 
Its power to hold the uterus depends upon the condition of the 




__£>q3^ 



Fig. 80. — Final step in the correction of retroflexion. When the uterus has been 
manipulated as in Fig. 79 then the external fingers pressing deeply through the ab- 
dominal wall find themselves back of the fundus. They press the fundus forward, 
after the internal fingers, in front of and under the cervix, have lifted the uterus up- 
ward. The uterus is thus brought into the normal position. If now it be desired 
to introduce a pessary, the internal fingers must keep the cervix high up and far 
back. On the palmar surface of these internal fingers the pessary is introduced. 

levator ani muscles and the elasticity of the vagina. If the vaginal 
elasticity is gone and the levator ani muscles are too lax, the pessary 
will not remain in place. In retrodisplacements of the uterus 
the pessaries of Hodge and Smith are the ones to be used. 

In some cases of cystocele, with the uterus in normal position 
a small pessary is introduced so that the narrow anterior end does 
not come within an inch of the symphysis. The pessary is held 



9 6 



MEDICAL GYNECOLOGY 



in place by its posterior bar in the posterior fornix behind the 
cervix. The anterior end lies along the anterior end of the vagina 
and lifts up and supports the cystocele. 

Skene's pessary is sometimes of value in supporting a cystocele 
if the uterus is normally placed. The upper end of the pessary 
is fixed behind the cervix. The anterior end is a broad bar of a 
very high curve, supported by a wedge underneath it. The poste- 
rior bar fits back of the cervix and the high anterior end fits be- 
hind the symphysis and lifts up and supports the hernia of the 
bladder (Fig. 85). 




Fig. 81. — The first step in introducing the pessary. The uterus has been brought 
into anteflexion. The internal fingers keep the cervix high up and back, the pal- 
mar surfaces of the two first fingers are turned so that they look almost upward, 
the pessary is held so that its edge does not touch the urethral canal. The pessary 
is passed into the vagina on the palmar surfaces of the internal fingers. The two 
last fingers of the left hand are flexed upon the palm. 



The round, hard-rubber pessaries are used for marked descent 
and prolapse of the uterus and vagina (Fig. 86). In using the 
round ring pessaries a good perineum and fair levator ani muscles 
are necessary to their retention. These rings are introduced over 
the palmar surface of two fingers passed into the vagina. The 
ring is passed into the vagina in a diameter midway between the 
transverse and antero-posterior diameter of the vagina. The 
internal fingers then manipulate the ring so as to bring its opening 
as closely as possible over or up to the cervix and the ring lies 




Fig. 82. — Second step in introducing a pessary. After the pessary has been 
introduced so that its upper bar is in the anterior fornix the two internal fingers pass 
up over this bar and are turned so that the palmar surfaces look downward. 




Fig. 83. — Third step in introducing the pessary. The tips of the internal 
fingers over the posterior bar push this bar down under the tip of the cervix and 
carry it up into the posterior fornix. The anterior bar is held by the tip of the index- 
finger of the right hand so that it does not press against the urethra as it slips into 
the vagina. 




3 Q-S S £ 



Fig. 84. — Pessary in place. After the pessary is in place the patient should be 
told to press down as if at stool to see if the pessary is accurately fitted. There is 
no objection to introducing the bivalve speculum and carrying out any cervical, 
vaginal, or intrauterine manipulation or intravaginal packing with glycerin and 
gauze. The presence of the pessary does not interfere with these therapeutic 
procedures. 



METHODS EMPLOYED IN MEDICAL TREATMENT 



97 



transversely to the axis of the vagina. The ring, if too small, 
slips out readily after a few hours. If too large, it causes pain by 
pressure on the rectum and vaginal walls. The Menge pessary 




Fig. 85. — Skene's pessary, which is of aid 
in a few cases of cystocele. As a rule, how- 
ever, the weight of the vaginal wall and blad- 
der pushes this anterior end down and out 
of the vagina. Only when the posterior bar 
and lumen are held firmly by the cervix will 
the anterior end support a cystocele. 




Fig. 86. — Round rings of hard 
rubber or wood, to support a de- 
scended uterus or to support a cys- 
tocele by lying transversely to the 
axis of the vagina and around or 
just below the cervix. This ring 
has been modified by a bar fitted 
at right angles to the ring which 
keeps the ring in its correct posi- 
tion. This is found in the Menge 
pessary. 




has a bar fitted at right angles to the ring. This bar lies in the 
vaginal canal and keeps the round pessary in the proper plane. An 
existing vaginitis, especially senile vaginitis, should be first healed. 
Douches should be taken daily. 

Inflammation of the vagina, 
urethra and bladder, erosions, 
acute inflammation of the ad- 
nexa, are contraindications. A 
pessary should never excite pain, 
and on pressing, bending, or def- 
ecation it should cause no annoy- 
ance. It is claimed that 10 to 15 
per cent, of all retroflexions can be 
cured by the use of the pessary. 

There is used for the support 
of a prolapsed uterus a combina- 
tion of an intravaginal cup with a stem and an abdominal belt 
which, by the aid of strap supports, keeps the cup and stem 
pessary within the vagina, and so keeps the uterus within the 
7 



Fig. 87. — Intrauterine stem pes- 
sary, to be introduced into the cervix. 
This is done through a bivalve or 
other speculum (not a Ferguson). 
The pessary is held by a fine pair of 
dressing forceps. After the stem is 
introduced into the uterus, the vagina 
is packed with gauze for twenty -four 
hours to keep the pessary from being 
forced out of the cervix and uterus. 



go MEDICAL GYNECOLOGY 

pelvis. This is the so-called Lavedan's cup pessary — a cumber- 
some and uncomfortable apparatus. 

The intrauterine stem pessary may be used where there is a 
really marked stenosis which causes dysmenorrhea and sterility. 
It is perhaps more indicated in the treatment of hypoplasia and 
stubborn amenorrhea due to hypoplasia (Fig. 87). 

The objection to the use of an intrauterine pessary is the irrita- 
tion of the endometrium and of the lining of the cervix. It seems 
to be often used for sterility, in the belief that many of these cases 
are due to stenosis of the cervix or of the external or internal os. 
Some of these are made of parallel bars of wire, so as to permit 
the upward movement of the spermatozoa. All of these imple- 
ments are capable of harm in the presence of cervical, uterine, or 
pelvic inflammation. 



PRESSURE THERAPY FOR RESORPTION AND STRETCHING 

The patient is placed in a mild Trendelenburg position. The 
Trendelenburg position elevates the uterus and its adnexa. A 
bag of sand may be placed on the abdomen to produce intrapelvic 
pressure. A condom or colpeurynter filled with shot or quick- 
silver is introduced into the vagina. A special apparatus has been 
devised by Pincus and Halban for this purpose. The action of 
the vaginal pressure is a pull on the shortened parametrium or 
bands, especially if one end of the bands or adhesions is attached 
to the pelvic wall. Through pressure of the sand-bag on the 
abdomen and pressure of the bag in the fornices the uterus is 
elevated and exudates are compressed. During the compression 
between these two forces the internal genitalia are in a state of 
anemia, subsequently followed by reactive hyperemia. This 
diminishes the chronic edema of the connective tissue and increases 
lymphatic resorption. The same purpose can be well obtained by 
introducing Champetier de Ribes bags into the vagina and distend- 
ing them with water. If hot water is used, the added value of the 
thermic effect is obtained. This treatment is suitable in the chronic 
stages of inflammatory diseases; never in the acute or subacute 
stage. Fever is a contraindication. It is best indicated in chronic 
parametritis with sclerosis of the connective tissue, especially if 




Fig. 88. — Half-section, showing the gauze in the fornices and vagina as used 
for the purposes of intravaginal pressure-therapy, and for other purposes in place 
of the routine use of cotton tampons. After the speculum is withdrawn only a 
slight bit of the gauze is allowed to protrude into the vulva, to render removal of 
the gauze by the patient easy. 



METHODS EMPLOYED IN MEDICAL TREATMENT 99 

there is edema. It is never to be used in pyosalpinx or pus cases. 
This procedure is most strongly indicated, perhaps, in involvement 
of the uterosacral ligaments. The subsequent treatment consists 
in massage and bimanual stretching. A modification of this idea 
is well obtained by packing the fornix thoroughly with gauze with 
the patient in a slight Trendelenburg position, perhaps with a sand- 
bag on the abdomen. 

I have long discontinued the use of small vaginal cotton tampons 
for this purpose because of the difficulty in making them remain in 
the desired position. I use long strips of 6- inch wide sterile gauze. 
The patient is placed in a mild Trendelenburg position. With the 
aid of a vaginal bivalve speculum the vagina is cleansed with 
carbolic or lysol solution and any required treatment of the cervix, 
uterus, or fornices is carried out. Boroglycerin to the amount of 
i or 2 ounces is then poured into the speculum. With a very 
long pair of dressing forceps one long strip of the sterile gauze 
is gently and firmly packed into one lateral fornix, then into 
the posterior fornix, and then into the other lateral fornix, elevating 
the uterus. This packing is continued to one side and then to 
the other until the posterior fornix is filled and the edge of the 
external os is reached. Another strip of gauze of the same char- 
acter is then packed into the anterior fornix until the edge of the ex- 
ternal os is reached. Then both strips at the same time are 
packed thoroughly into the upper part of the vagina, and less 
thickly into the lower half of the vagina. If desired, the patient may 
be left in this position, with or without a sand-bag on the abdomen, 
for ten to twenty minutes. This packing is left in place for 
twelve to twenty- four hours, during which period, when the patient 
is in standing position, the action of intra-abdominal pressure and 
the weight of the pelvic organs presses upon the vaginal packing 
and pelvic exudates are compressed (Fig. 88). The uterus having 
been lifted up and the various ligaments or adhesions having been 
put on the stretch, there results, after several treatments, a diminu- 
tion of exudate, a stretching of ligaments and adhesions, as a 
result of which uteri which are retrodisplaced through shortening 
of the uterosacral ligaments, or which are held in fixed retro- 
flexion either by contact adhesion or by peritoneal adhesions, 
may be restored to a normal position. Another benefit is the 



IOO MEDICAL GYNECOLOGY 

relief of sensitiveness and backache produced by inflammation, 
infiltration, or shortening of the uterosacral ligaments, or by the 
tugging of peritoneal adhesions. This method, when carried out 
with great care, and supplemented by the use of prolonged hot 
vaginal douches, and further aided by massage and bimanual 
stretching of the uterosacral ligaments and gradual bimanual 
attempts at replacing a displaced or retroflexed uterus, not infre- 
quently gives excellent results in cases not complicated by pus 
formation, especially if the treatment is gently carried out and 
is not attempted too soon after the occurrence of adhesions or 
infiltrations. In addition, we get the markedly beneficial de- 
pleting action of the glycerin on the pelvic tissues and on the uterus 
and cervix. 

COUNTER-IRRITATION 

The abdominal wall at the so-called points of Morris may be 
painted with tincture of iodin, or we may apply to one or both 
points a mustard plaster or a cantharides plaster. These are used 
for the relief of pain due to chronic pelvic inflammation, especially 
in involvement of the ovaries, and are best applied when the 
pain is most severe, which usually occurs before menstruation. 

A cantharides plaster two inches square is applied at Morris' 
points, which are situated below and external to the umbilicus. 
If a line is drawn to the umbilicus from the external spine of the 
ilium (the line on which McBurney's point is measured), a point 
distant one and one-half inches on this line from the umbilicus 
represents a point which corresponds to the lumbar plexus of 
the sympathetic system. The skin is washed with soap and water 
and then smeared with a very thin layer of vaselin and the plaster 
is then applied. It is held in place by two cross-strips of adhesive 
zinc plaster and is allowed to remain in contact with the skin until 
a bleb is formed, which usually takes from six to eight hours. 
The plaster is then removed and the bleb is incised to permit the 
accumulated serum to escape. The plaster is then dressed by 
being thoroughly covered with zinc ointment, over which a gauze 
dressing, held in place by zinc adhesive plaster, is made. This 
dressing should be changed daily until the blister is healed without 
the loss of skin. 



METHODS EMPLOYED IN MEDICAL TREATMENT IOI 

Ceratum cantharadis may be used. It is spread on adhesive 
plaster, leaving a margin of an inch which is to adhere to the skin. 
This is left in place for eight hours, or for five hours only, and 
then followed by a hot flaxseed poultice. 

Collodium cantharidatum (60 per cent.) may be applied in two 
or three coats with a camel's-hair brush. 

Ready-made mustard plasters may be used. These may also be 
made by using black mustard, and flour or flaxseed meal, half and 
half, or by using three parts of white mustard to one part of flour. 
They should be applied hot for twenty minutes to one-half hour. 
If it is desired to apply such a mustard plaster for hours, it should 
contain one to three teaspoons of mustard to a poultice of flaxseed. 

BIMANUAL MASSAGE (VAGINO-ABDOMINAL) IN CHRONIC CON- 
DITIONS 

Vagino-abdominal manual massage has a depletory action, 
through stimulation of the circulation and through stimulation 
of the lymph- current. Venous hyperemia and congestion are di- 
minished and the vessels of the uterus are contracted through the 
rnechanical stimulation. If massage is prolonged, there occurs a 
secondary dilatation of the vessels. Through gentle massage the 
uterus becomes smaller and harder. This results from mechanical 
stimulation of the muscle and through mechanical irritation of 
the cervical ganglia. 

The Brandt method is used for stretching pathologic bands, 
for lifting the uterus, and for massaging infiltrations. The patient 
is on the table and the two fingers of one hand are introduced as 
in bimanual examination. Bladder and rectum should be empty. 
The external hand pressing through the abdomen is brought 
down to the internal hand. The external hand makes light cir- 
culatory rubbings of the skin to push the intestines aside, and then 
continues gently deeper circulatory rubbings in the direction of the 
introduced fingers. In massaging exudates the periphery should 
be massaged to empty the lymph- vessels, gradually passing 
gently toward the center of the exudate. Massage of the uterus 
is carried out in the same way and the tubes and ovaries are like- 
wise so treated. 

The most important action of vaginal bimanual massage con- 



102 



MEDICAL GYNECOLOGY 



sists in the purely mechanical stretching of sclerotic bands and 
adhesions and the loosening of abnormal adhesions. The uterus 
and the portio are gradually lifted and pulled in various directions 
(Fig. 89), stretching parametritic bands or adhesions on the poste- 
rior surface of the uterus. The external hand passes over the 
posterior surface of the uterus, the internal ringers are applied to 
the portio, and gentle, steady, slight pulls of gradually increasing 
duration are made first in one lateral fornix and then in the other, 




_3 CxSStZ- 



Fig. 89. — First step in stretching the uterosacral ligaments. The internal 
fingers back of the cervix pull the cervix upward and put the posterior parametrium 
and the uterosacral ligaments on the stretch. This procedure done gently and 
intermittently at each treatment will in the course of time, when supplemented by 
hot douches and by vaginal pressure therapy, aid in so stretching the shortened 
ligaments that a retroflexed or retrodisplaced uterus can be brought into normal 
position and held so by a Smith or Hodge pessary. 



and then in the posterior fornix (Fig. 90). The subsequent 
manipulation is the same, only carried out gradually and through 
successive treatments, as is used in replacing the mobile uterus. 

The indications for bimanual massage are old parametritic 
exudates, but never pyosalpinx or when there is fever. This 
method removes the edema in the parametrium and about the 
adnexa. It is especially valuable in the case of old organized 
sclerotic changes (Oskar Frankl). 



METHODS EMPLOYED IN MEDICAL TREATMENT 



IO3 



ABDOMINAL MASSAGE 

In the individual who takes a normal amount of exercise mus- 
cular contractions produce a return flow through the lymphatics of 
the products of metabolism. General massage exerts the same 
effect as exercise, but does not imply the use of physical and nerv- 
ous force on the part of the patient. Massage affects the muscles, 
the general circulation, and the nervous system. It may be carried 




Fig. 90. — Bimanual massage, for stretching the posterior parametrium and 
uterosacral ligaments. The external hand, when it can be brought back of the 
uterus, aids the internal fingers in performing this manipulation. Such treatment, 
extending over many weeks and supplemented by hot douches and vaginal pressure 
therapy, is often an essential preliminary in restoring a retroverted, retroflexed, or 
retrodisplaced uterus to the normal position, in which position it can be held by a 
Smith or Hodge pessary, to the great relief of backache. 



on upon the dry skin or, better, with the use of vaselin or cocoanut 
oil. In many individuals the value of massage consists in sub- 
stituting or stimulating the above-mentioned processes. In addi- 
tion, massage has a soothing effect and a trophic influence on the 
nervous system. General massage is of value, especially if aided 
by the faradic current, in neurasthenia, in feeble states, and in ner- 
vousness (Wood). 

Local massage is used to exert an effect on local conditions. 
Tender spots which are due to congestion or to gouty exudations, 



io4 



MEDICAL GYNECOLOGY 



especially if aided by the faradic current, are benefited by local 
massage. Kneading associated with local massage affects the 
local circulation, stimulates muscle fibers, breaks up masses of 
adhesions, and causes exudations to disappear. 

The following procedures are of special value in cases with 
loose abdominal walls, in weak individuals, especially if they 
suffer from habitual constipation, and after laparotomy. 




Fig. 91. — A manipulation in abdominal massage, for loose abdominal walls. 
Longitudinal folds of the abdominal wall are grasped between the thumb and four 
fingers of either hand and are rubbed and kneaded. This manipulation is especially 
valuable shortly postpartum and after laparotomy. 



The abdominal walls should be well kneaded, beginning at 
one side of the abdomen and passing gradually over to the other 
side. Longitudinal folds of the entire abdominal wall should be 
compressed, kneaded, and lifted up by a firm hold taken between 
the thumbs on the one side and the other four fingers on the other 
(Fig. 91). Exerting pressure on one side of the abdomen with 
the palmar surface of one hand, the closed fingers of the other 
hand should make circular motions pressing the ascending and 



METHODS EMPLOYED IN MEDICAL TREATMENT 



I05 



descending colon against the posterior abdominal wall (Fig. 92). 
When the abdomen has become less resistant, deep pressure with 
the thumb and forefingers separated should attempt to grasp the 
ascending and descending colon and the sigmoid between the 
fingers for kneading manipulation. 

Bumm massages not earlier than two hours after eating. The 
patient lies flat, with somewhat bent hips and knees. The patient 




Fig. 02. — Kneading the abdomen. The flat or closed hand is pressed down on 
one side of the abdomen and the closed fist of the other hand makes deep rub- 
bings and rotary movements on the other half of the abdomen. This manipula- 
tion affects not only the abdominal wall but also the intestinal tract. After both 
sides of the abdomen have been treated, the kneading is continued along the 
course of the colon from the cecum to the sigmoid. 



breathes easily. Circulatory rubbings are performed, followed 
by kneading of the muscles of the abdominal wall and then the 
kneading of the colon (Fig. 93). The kneading is done with the 
palmar surface of the three longest fingers of one hand, which 
press into the abdominal wall and make small circulatory motions, 
pressing deeper, in order to knead the colon between the abdominal 
wall and the pelvic bones. The other hand is placed upon the 
working hand and supports it in all its movements. This manipu- 



Io6 MEDICAL GYNECOLOGY 

lation is begun in the region of the cecum and follows the direction 
of the colon. 



Fig. 93. — Abdominal massage. Circulatory rubbing or rotary movements are 
made by the fingers of one hand supported by the other hand. The fingers are 
pressed down deeply to catch the intestine between the fingers and the posterior 
abdominal wall. Especial attention is paid to the colon (after Bumm). 




Fig. 94. — Abdominal massage. The patient's abdomen is pressed against by 
the flat of the two hands; she is told to fill her lungs and to press up with the ab- 
dominal muscles against the resistance applied to the abdomen. This is repeated 
several times. 

The palmar surface of both hands should be placed on the 
abdomen above and below the umbilicus and the patient should 



METHODS EMPLOYED IN MEDICAL TREATMENT I07 

be told to fill the lungs and exert pressure through the abdominal 
muscles in an attempt to lift the hands pressed against the ab- 
domen (Fig. 94). Then again the patient is told to fill the lungs 
and to press upward with the abdominal muscles, and then the 
palmar surface of the two hands press gently but firmly on the ab- 
dominal wall, in an effort to overcome this resistance of the abdominal 
muscles (Fig. 95). Each of these manipulations should be done 
ten times. The patient lying perfectly flat and the legs below 
the knee being held down gently, she should slowly and grad- 




Fig. 95. — Abdominal massage. The patient fills her lungs and presses up with 
the abdominal muscles. The two flat hands are then applied and pushed down 
firmly in the attempt to overcome the abdominal resistance offered by the patient. 
This is repeated several times. 

ually, with her shoulders thrown back, raise herself to a sitting posi- 
tion, and then gradually return to the lying position. This manip- 
ulation should be done by the patient at her home, morning and 
night. Another procedure to be carried out by the patient at her 
home is the act, when lying flat, of lifting her legs, held straight, 
upward slowly to a position at right angles with the body, and then 
letting them slowly down to a straight fine with the body. This 
should be done ten to twenty times, morning and night. Massage 
and the action of the sinusoidal current are fully discussed in the 
section on Constipation. 



io8 



MEDICAL GYNECOLOGY 



ABDOMINAL SUPPORTS 

Elastic abdominal belts, held in place and prevented from 
slipping upward by straps or rubber tubing which passes between 

the thighs, are often of great 
value, especially in sup- 
porting the loose abdominal 
walls so often associated 
with gastro-enteroptosis and 
various degrees of hystero- 
ptosis (Figs. 96, 97). In 
these cases they give sup- 
port to all the intra-abdom- 
inal organs, give the patient 
a sense of elasticity, and tend 
to diminish pelvic and ab- 
dominal congestion and the 
various associated dyspeptic 
annoyances. In addition, a 
binder is of great value 

Fig. 9 6.-The Storm binder, one of the after the fifth month of P re g" 

best of the abdominal supports for loose ab- nancy in supporting the ab- 
dominal walls, for splanchnoptosis, and for . 

use during the later months of pregnancy. dommal wall and the tundus 





Fig. 97. — The Storm binder, side and back views. 



METHODS EMPLOYED IN MEDICAL TREATMENT 



I09 



of the uterus, taking the strain of 
walls. In the post-partum period, 
when the patient first gets up and 
about, several weeks and sometimes 
months elapse before the abdominal 
wall and the intra-abdominal organs 
are involuted. During this period, 
in which Nauheim baths, the sinu- 
soidal current, and abdominal mas- 
sage are used, the abdominal 
walls may be supported by the aid 
of such an elastic abdominal belt, 
which in all cases should be made 
and fitted to the individual figure 
by the accurate measurements and 
fitting of an experienced manufac- 
turer. To a very great degree the 
need of such belts is diminished by 
the wearing of what are known as 
straight-front corsets, which support 
the abdominal wall and lift up the 
lower half particularly of the abdom- 
inal contents (Fig. 98). These cor- 
sets are devised to avoid contraction 
of the waist and of the thorax. The 
ordinary straight- front corsets are 
harmful in the post-partum period, 
nor should they be permitted in the 
later months of pregnancy. The 
belt and corset should be applied 
while in the lying position. The 
question of abdominal supports is 
fully discussed in the section on Con- 
stipation. 



stretching off the abdominal 




Fig. 98. — The Heath corset, 
one of the best of the straight-front 
corsets for supporting the intra-ab- 
dominal organs in splanchnoptosis. 
It is so loosely made in its upper 
half that it does not compress the 
abdomen, nor does it compress the 
thorax or breasts. 



THE PRODUCTION OF PELVIC HYPEREMIA AND ANEMIA 
The production of arterial hyperemia increases the nutrition of 
tissues, stimulates local tissue change, and increases the re- 



IIO MEDICAL GYNECOLOGY 

generative functions. If the tissues and cells are better nourished 
as a result of hyperemia, and if their antitoxic power is increased, 
the cells and their energy are preserved. The production of hyper- 
emia in the pelvis is indicated in edematous swelling of the geni- 
talia, in old hard exudates, in non-purulent inflammations of the 
adnexa in the chronic stage, in old parametritis, in infiltration of 
the uterosacral ligaments. Hyperemia makes scars and sclerosed 
bands due to parametritis and perimetritis more succulent, and 
renders subsequent stretching easier and less painful. It should 
not be produced in the presence of fever. If, however, cells and 
tissues are severely involved, then the increased hyperemia and 
increased tissue changes hasten the purulent degeneration of the 
tissues (Oskar Frankl). 

The production of anemia or contraction of the vessels in 
inflamed pelvic organs has an antiphlogistic and depletory influence. 
When produced in congested hyperemic areas, it diminishes 
bleeding or the tendency to bleeding. It is indicated in acute 
inflammatory conditions, such as perimetritis, parametritis, 
endometritis, salpingo-oophoritis, in hyperemia, climacteric bleed- 
ings, other bleedings, etc. 

Changes in the circulation of the pelvic vessels may be produced 
by applications to the abdomen or to the vertebrae, by douches, 
by sitz-baths, and by full tub-baths. 

A long water bag is of value for applications to the lowest verte- 
brae (Figs. 99, ioo). In this location we accomplish with cer- 
tainty a reflex effect on the uterus. If filled with cold water, it is 
used in sexual excitement, nymphomania, and for pollutions. If 
filled with hot water, it is of value for menorrhagia and metror- 
rhagia. Olshausen places bleeding patients on a bag of hot sand. 
Through such warm applications to the lower vertebrae we readily 
cause uterine contractions. 

Abdominal Applications 
The use of the ice-bag and of the hot- water bag applied to the 
abdomen are too well known to require elaboration. The rules 
governing their application are the same as those noted below. 
The ice-bag should not be applied directly to the skin, but should 
be separated from the skin by a dry cloth or compress. It should 



METHODS EMPLOYED IN MEDICAL TREATMENT 



III 



be removed at intervals as soon as it causes local discomfort. In- 
stead of the ice-bag, the cold coil may be used. Cold is of value 
in acute inflammatory pelvic conditions. 

Abdominal applications by means of moist cloths or towels 
are of great importance for the production of pelvic anemia or 




Fig. 99. — Long rubber water-bag, to be applied to the spine when filled with hot 
or cold water to cause either pelvic anemia and contractions of the pelvic vessels 
(hot water) or pelvic hyperemia (cold water). Two little straps are attached to the 
bag so that bands, passed through them and around the abdomen, keep the bag in 
place even if the patient turns on her side. The upper end is rolled in and the 
string is laced over it. 



hyperemia. The moist cloths should be covered by a dry per- 
meable towel. 

Anemia in the pelvic organs can be caused by moist cool ap- 
plications (under 70 F.), which must be changed often. Such 
applications in the region of the hypogastrium have the same effect 
as a prolonged cool sitz-bath. They have an antiphlogistic and de- 
pletory influence on the pelvic organs. They are used in hyper- 
emic and acute inflammatory changes, such as perimetritis, parame- 




Fig. 100. — Chapman's water-bag, to be applied to the spine for the same purpose as 
mentioned in Fig. 99. 



tritis, endometritis, salpingo-oophoritis. Cool local applications are 
used in pruritus vulvas. 

Hyperemia can be produced by warm applications, 95 to 105 
F., which should be changed often. They cause hyperemia of the 
skin and of the pelvic organs, and hot ones (105 to 112 F.) cause 
a permanent dilation of the vessels. Warm and hot applications 



112 MEDICAL GYNECOLOGY 

are used in menstrual colic, for old hard exudates, in the chronic 
stages of inflammation of the uterus and adnexa when there is no 
fever, no pus, no pregnancy, and no marked bleeding. They are 
also used locally in vulvitis and Bartholinitis. 

Hyperemia can be produced by stimulating applications which 
consist of cool moist cloths (under 70 F.) covered with a dry towel 
which is not impermeable. They are changed only every four or 
five hours. A Priessnitz bandage may be used. It is a broad linen 
band 9 feet long. The first third is moistened in cold water and 
wrung out. It is applied to the abdomen and the dry two-thirds 
are then wound around the body. Stimulating applications at first 
have the same action as the cool ones, but soon the moistened band 
becomes as warm as the blood, and a hyperemia or reaction takes 
place. This warm blood passes from the skin deep down and 
causes a dilation of the vessels and an increased flow of blood to 
the internal genitalia. These stimulating applications mildly 
stimulate tissue change and resorption in the subacute stages of 
inflammation, such as exudates, etc. (Oskar Frankl). 

Vaginal Douches for the Production of Pelvic Anemia or 

Hyperemia 

The value of douches is represented by the cleansing effect, 
by the action of the medical ingredients, and, most important, 
by the thermic effect of the water. 

The patient should lie on her back on a douche pan ; the height 
of the bag should be 2 feet above the pelvis; the tube should be 
preferably of glass with closed ends, but with several lateral 
openings about the tip. Inasmuch as in prolonged douches the 
effect of temperature is desired, a water-bag containing 4 quarts 
may be made to last a quarter of an hour, if, during the taking 
of the douche, the rubber tube of the hot-water bag is compressed 
with the fingers as soon as the hot water is distinctly felt, the pres- 
sure being released every half minute to allow fresh water to run 
into the vagina and to exert its thermic influence. 

Anemia. — Cool douches (under 70 F.) of short duration 
stimulate the tone of smooth and striped muscle fibers. The 
musculature of the vessels is contracted by short cool douches, 
but this does not last long. Cool douches are used when there 



METHODS EMPLOYED IN MEDICAL TREATMENT II3 

is a tendency to prolapse and descent, when there is hyperemia, 
and when there are climacteric bleedings. Hot douches also 
stimulate the tone of smooth and striped muscle fibers if their 
duration is not too long. The vessel musculature contracts as a 
result of hot douches. Therefore hot douches stop bleeding, 
if they are not too prolonged (if taken for twenty minutes there 
results a subsequent relaxation of the vessel musculature). Short 
hot douches (105 to 11 2 F.) of 1 to 3 quarts are used for cli- 
macteric bleeding, for menorrhagia, and for the bleedings of 
uterine atony and uterine myomata. The contraction of the 
muscles of the pelvic floor occurs actively as a result of hot douches. 
Hyperemia. — Of greatest importance is the active hyperemia 
produced in the pelvic organs by warm and prolonged hot douches. 
Associated with the hyperemia is an increase in the lymphatic 
circulation, with increased local tissue change and resorption of 
exudates. Warm douches of 90 to 105 F. in large amounts 
are used for spastic dysmenorrhea and for the colic of metro- 
endometritis if the adnexa are free. Prolonged hot douches are 
used up to 112 F. in amenorrhea, slight menstruation, chronic 
endometritis and metritis, subinvolution. They are contraindi- 
cated where there is fever, in fresh inflammatory processes, in 
the presence of purulent accumulation, such as pyosalpinx. Very 
hot douches, 120 F. or more, and prolonged in duration, are used 
for sclerotic and shrunken tissues and bands associated with dis- 
location of the internal genitalia, and for hard, firm exudates, in 
the fever- free stage. Hyperemia prepares the tissues for massage. 



SlTZ-BATHS FOR THE PRODUCTION OF PELVIC ANEMIA OR HYPEREMIA 

The use of this procedure, as a rule, demands a deep sitz-bath 
tub, with a support for the back, two-thirds full of water (Fig. 
100 a). The patient should wear a gown, stockings, and slippers. 
When seated, the pelvis up to the umbilicus and the thighs almost 
up to the bend of the knees are covered with water. A shawl or 
blanket is thrown about the shoulders and covers the patient as 
she is seated in the tub. After the bath the patient at once goes 
into bed on an extra sheet, with which she is quickly dried, and 
is then covered with blankets. 

8 



114 



MEDICAL GYNECOLOGY 



A sitz-bath in which the patient is seated in a bath-tub with suf- 
ficient water to cover the body up to the umbilicus may be given as a 
modified form of the Nauheim bath if salt (3 pounds) and calcium 
chlorid (3 ounces) are added. The effect of such a bath is to 
influence pelvic congestion and to alter the pelvic circulation. It 
is, however, associated with no constitutional benefit, as in the 
case of the complete Nauheim bath. 

Anemia of the pelvic structures is produced by a cool, prolonged 
sitz-bath, 50 to 65 F., duration five to thirty minutes, which causes 
long vessel contraction of the genital organs. The indications are 
climacteric bleedings, congestion of the pelvis and its associated 

dysmenorrhea and menorrhagia, pruri- 
tus vulvae, and vaginismus depending 
on a neurasthenic base. They are 
contraindicated in anemic and weak 
individuals and in uterine colic. 

Anemia of the pelvic structures is 
also produced by a tepid sitz-bath, 70 
to 85 F., five to fifteen minutes, which 
causes a contraction of the vessels in 
the pelvis. It has a restful effect and 
can be used in weak individuals and 
in those who cannot at first stand the 
colder baths. It is useful in inflam- 
mation of the uterus and vagina. 
Hyperemia of the pelvic organs is produced by a short, cool 
sitz-bath, 50 to 65 F., and lasting one to five minutes, which causes 
a contraction of the peripheral vessels and of the vessels of the pel- 
vic organs. After leaving the bath there is a reactive dilatation of 
the skin vessels and of the vessels of the pelvis. This bath causes 
a reactive flow of blood to the inner genitalia. This short, cool bath 
is used in those cases in which we wish an active hyperemia and a 
stimulation of the motor and secretory functions of the uterus, as in 
amenorrhea, leukorrhea, in not too weak individuals; in hypo- 
plasia, in asthenic uteri with metrorrhagia and menorrhagia, in 
chronic metritis and subinvolution. It is contraindicated in acute 
and subacute inflammations of the genitalia, in pregnancy, and 
when there is great pain. 




Fig. 100 a. — Sitz-bath Tub. 



METHODS EMPLOYED IN MEDICAL TREATMENT 115 

Hyperemia of the pelvic organs is produced by warm sitz-baths, 
90 to 105 F., ten to thirty or forty-five minutes, which cause a flow 
of blood to the pelvis and its organs, and are used to cause a hy- 
peremia of the genitalia, to stimulate resorption, and to exert a 
sedative effect. They are indicated in hypoplasia, amenorrhea 
and slight menstruation, in spastic dysmenorrhea, in chronic 
metro-endometritis and chronic parametritis and perimetritis, in 
hard exudates after the fever stage is over, in salpingo-oophoritis 
when there is much pain without fever and when there is no pus. 
They are also useful in the chronic stages of cystitis or tenesmus, 
but never for acute gonorrhea; never to be used in pregnancy, 
menorrhagia, metrorrhagia, or accumulation of pus in the pelvis. 



ELECTRICITY 

The Galvanic Current. — The positive pole (anode) has a 
hemostatic, anesthetic effect. It stimulates contraction, narrows 
the vessels, and is antimycotic. The negative pole (kathode) pro- 
duces hyperemia, diminishes pain, and aids resorption. For the 
use of galvanism one needs : 

A battery with a current up to 150 milliamperes (Fig. 101). 

Two electrodes. 

An inactive abdominal electrode of lead, which should con- 
stitute a wide plate separated from the skin by a thoroughly 
moistened pad (Fig. 103). 

For the vagina, special electrodes are used (Fig. 102, a 
and b). 

For the uterus, aluminum electrodes of the shape of a sound are 
necessary with the vaginal part made of hard rubber (Fig. 104, b, 
c, d), or else olive-shaped removable tips are used, which are to be 
fitted on the end of an intrauterine holder. 

Intrauterine galvanism is to be used only when inflammation 
of the adnexa is absent. Thorough antiseptic precautions must 
be used before the sterile unipolar electrode is introduced into the 
uterus. We begin with a current of 1 milliampere and gradually 
go up to 30 to 50 milliamperes for three to seven minutes twice a 
week. Severe pain should never be caused. The current is in- 
creased gradually and is gradually reduced. The abdominal and 



n6 



MEDICAL GYNECOLOGY 



intrauterine electrodes should be held quietly and steadily. With 
galvanism the unipolar electrode is always used. 

Indications for the Use of the Galvanic Current.— Gal- 
vanism for myomata only stops the bleeding temporarily, but im- 
proves the nervous symptoms and diminishes pain. It does not 
diminish the size of the tumor. Only interstitial myomata are to 
be treated. The effect on subserous tumors is nil and gangrene 




Fig. 101. — Battery for the production of galvanic or faradic currrent or of both 
currents combined. The strength of the galvanic current applied is registered by 
the meter, and is increased by the rheostat. 



of the capsule and degeneration are to be feared in the case of sub- 
mucous myomata. 

For the bleeding and pain of small interstitial myomata in 
women near the climacteric age and for the bleeding of subinvolu- 
tion the anode is used within the uterus and the inactive electrode 
is the abdominal plate. In the treatment of bleedings as many 
as fifty sittings may be necessary and currents up to 150 to 300 
milliamperes have been used. The hemostatic effect often comes 



METHODS EMPLOYED IN MEDICAL TREATMENT 



117 



only after many treat- 
ments, and at first there 
is apt to be an increased 
flow of blood, which is 
of no significance. If, 
however, the bleedings are 
markedly increased and last 
long, galvanism will not 
bring about a cure. Frankl 
advises the application of a 
cold Priessnitz bandage for 
a half hour after each treat- 
ment. 

For dysmenorrhea and 
stenosis of the internal os: 
negative electrode intrauter- 
ine — positive plate abdom- 
inally, 20 to 40 milliam- 
peres. By some, the posi- 
tive electrode is used within 
the uterus. 




Fig. 102. — a, Vaginal metal electrode; b, 
vaginal non-metallic electrode; c, small elec- 
trode for external use (Frankl). 



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Fig. 103. — The large abdominal plate of lead, with attached lining which is thor- 
oughly moistened before being applied. 



u8 



MEDICAL GYNECOLOGY 



For amenorrhea of hypoplasia: negative electrode within the 
uterus, lead plate on abdomen, 30 to 50 milliamperes. 

For ovarian neuralgia: positive electrode in the vagina, lead 
plate on abdomen. 

For vaginismus : positive plate on the vulva, negative on sac- 
rum — weak current five minutes. 

For pruritus vulvae : non-metallic positive electrode in the vagina, 
negative for ten minutes on the affected area. 

The Faradic Current.— The faradic current (primary) causes 




Fig. 104. — a, Bipolar vaginal electrode for faradism; b, c, d, intrauterine elec- 
trodes of different calibers for galvanism or faradism; e, intrauterine bipolar elec- 
trode for the faradic current. 

contraction of smooth and striped muscle fiber. The secondary 
current acts on the nerve structures and diminishes pain. 

The intensity of the current is fitted to the subjective reaction of 
the patient by gradual increase in strength for ten to twenty 
minutes. 

For the faradic current the same electrodes as in galvanism are 
used, but bipolar electrodes, which do away with the use of the 
abdominal plate, may be employed. These are fitted for use in 
the vagina and uterus (Fig. 104, a and e). The indications are: 

Subinvolution — which is treated by vagino-abdominal faradism 
or by bipolar intrauterine faradism to stimulate contraction. 



METHODS EMPLOYED IN MEDICAL TREATMENT 



II 9 



Amenorrhea due to hypoplasia — treated by utero-abdominal 
faradic current or by bipolar intrauterine faradism. 
Dyspareunia — vagino-abdominal current. 
Ovarian neuralgia — vagino-abdominal current. 
Vaginismus — bipolar faradic. 

TABULATED INDICATIONS 

Positive Pole (Anode) [ Interstitial myoma (anode intrauterine) 

Hemostatic \ Ovarian neuralgia (anode in vagina) 

Anesthetic [ Vaginismus (anode on vulva, kathode on sacrum) 

1ST t" P 1 (K th d "i f dysmenorrhea (kathode intrauterine) 
° P A . J Amenorrhea (kathode intrauterine) 

» f -u f - 1 Pruritus vulvae (kathode on affected area, positive in 

neS e 1C [ vagina) 



Faradic Current 

Contracts Muscle 



Subinvolution ( vagino-abdominal or 
\ bipolar intrauterine 

A , f utero-abdominal or 

Amenorrhea { , . , . . . . 

\ bipolar intrauterine 



Anesthetic Dyspareunia \ . , , . , 

\ r\ • i • ) vagino-abdominal 

l Ovarian neuralgia ' 



Vaginismus (bipolar vaginal) 

The value of electricity in the treatment of splanchnoptosis, in 
post-partum treatment, etc., is shown in the section on Constipa- 
tion. 

INFLUENCE OF COOL AND COLD WATER APPLIED TO THE BODY 

Winternitz and his school have taught us the effect of water of 
different temperatures, and we have in hydrotherapy a powerful 
oxidation therapy whereby, through thermal and mechanical 
influences, activity and function, hunger and revulsion, can be 
produced in the cell. Hydrotherapy is a powerful curative method, 
since thermal and mechanical processes are the normal stimuli 
which arouse, strengthen, and regulate our organic functions in a 
physiologic way. An important effect of hydrotherapy results 
through its influence in changing and altering the blood distribu- 
tion, through the withdrawal of blood from congested and over- 
loaded organs, whereby circulatory disturbances may be corrected. 
The value of such a change and its influence upon congestions in 
the pelvis may be recognized when we consider that, next to the 
peripheral, the region of the pelvic vessels with their large venous 
plexuses is one of the most important elements in regulating blood- 
distribution and blood-pressure. Since the blood- channels and 
lymph-channels furnish the material for the organic functions and 



120 MEDICAL GYNECOLOGY 

for the nutrition of the organs, the circulation of any part is one of 
the most important factors in preserving its tone. 

The use of cool and cold water influences also a change in the 
morphologic character of the blood. It causes not alone an increase 
in the number of leukocytes, but likewise a decided increase in the 
number of red blood-corpuscles. A necessary factor in obtaining 
this result is the production of a decided hyperemia of the skin. 
If the skin remains cool for a considerable time, and if a complete 
reaction is not excited, this change does not result ; for then these 
cells, probably preformed blood-cells, do not enter the general 
circulation. Since after warm baths the increase in the number 
of erythrocytes is much less, this increase rests clearly upon changes 
in the circulation, in the heart's action, and in vessel tonus and tissue 
tonus. The blood richer in cells, richer in oxygen, makes the 
entire tissue change more complete, and causes an increased con- 
sumption of oxygen and an increased giving off of C0 2 . The re- 
sulting increased production of heat is reflexly regulated, and not 
by the degree or amount of heat withdrawn, but by the degree of 
the thermal nerve stimulus. Increased tissue metamorphosis is 
brought about reflexly through the influence of cold. 

The combination of cold with a mechanical stimulus increases 
the reaction. Cold water causes a contraction of the peripheral 
vessels and brings about, through thermal stimulation of the vagus, 
a slowing of the pulse, increases the oxidation processes in the body, 
and exerts a stimulating effect on the central nervous system. An 
important result of the contracting influence of cold is the increase 
in the venous tonus. Since cold temperature opposes the dilation 
of the peripheral vessels, mechanical stimuli are necessary to 
bring about a dilation, so that in hydrotherapy the mechanical 
stimulation, frottement or rubbing, must be combined with a 
thermal procedure to bring about peripheral relaxation; for only 
with the resulting sinking of the tension and of the blood-pressure 
(reaction) comes a feeling of well-being, and only those thermal 
processes can be considered trophic which influence the heat 
balance of the body, and only those can be considered tonic which 
lead to reaction (Wintemitz). 

Prolonged cool half baths, taken in a sitz-bath-tub with the 
water reaching to the umbilicus, or cool sponge baths are used for 
nymphomania and for pollutions. 



METHODS EMPLOYED IN MEDICAL TREATMENT 121 

In anemia and chlorosis we may use short procedures with 
water which do not extract heat and which are combined with 
mechanical rubbing to produce a reaction. We may begin with 
sponge-baths at 70 F., followed by rubbing of the body with a 
rough towel, and diminish the temperature by a degree or two every 
other day. This may be substituted at later periods by a more 
general rubbing with water or by tepid shower-baths. Sponge- 
baths and rubbings are of value to accustom patients, especially 
chlorotic and obese girls, to subsequent full baths. 



THE ACTION OF WARM BATHS 

A warm full bath causes an increase in the rapidity of the pulse, 
which persists after the bath. This occurs through its influence 
on the peripheral nerve-supply, which reflexly acts upon the vagus 
center, and which stimulates the accelerantes of the vagus. Very 
warm baths can, through weakening of the venous tonus, cause an 
increased resistance in the minor circulation, whereby, in spite of 
increased work on the part of the heart, no bettering of the circula- 
tion results. This is a weakening influence, since the heart is 
sufficient only when it is able to force the blood to the most distant 
organs, in whose capillaries alone tissue metabolism takes place. A 
very warm full bath causes usually no increased demand for nutri- 
tion and exerts no stimulating effect on the central nervous system. 

A full bath of tepid or warm temperature, from 85 to 95 F., 
relieves congestion of the genital organs, eases pain, and is condu- 
cive to sleep and rests the patient. During a menstrual period it 
diminishes the loss of blood. It is valuable in the treatment of the 
congestion and nervous symptoms of the climacterium in spastic 
dysmenorrhea, sleeplessness, excitability, etc. 

The vasomotor disturbances (flashes) of the climacterium are 
benefited by baths of a duration of fifteen to twenty minutes and 
of a temperature of 90 to ioo° F. They diminish the blood- 
pressure. 

Recently chlorosis and anemia have been treated with benefit 
by warm baths which add heat to the body, and which by with- 
drawing fluids from the body increase the thickness of the blood 
and increase the hemoglobin and the red blood-cells. 



122 MEDICAL GYNECOLOGY 



Full baths, lasting twenty minutes to one-half hour, are given 
three times a week at a temperature of from 95 to 105 F., and are 
followed by a cool rubbing or douche. Combined with these 
baths, rest and iron are of importance. 



THE NAUHEIM BATH 

A full bath of water at a temperature less than that of the body 
exerts, first, a stimulating action of the central nervous system 
and upon the trophic centers. If, at the same time, it withdraws 
heat from the body, it increases the process of oxidation. A bath 
of fresh water may be given with benefit or comfort at any tem- 
perature which does not produce too great a shock, if it is followed 
by a normal reaction or by mechanical rubbing which produces a 
reaction. Such a reaction results in a change in blood-distribu- 
tion, relieving the interior of the body of congestion, increasing 
the number of red cells in the circulating blood, increasing the 
tone of the heart, the vessels, and the tissues, and causing increased 
tissue metabolism, particularly through the stimulus given to the 
trophic central nervous system. Baths of a temperature less 
than that ordinarily borne with comfort may be made not only 
comfortable but still more valuable by the addition of chemical 
substances which exert a chemical stimulation upon the skin and 
the peripheral nerves. 

The following objections may be raised also against cool and 
cold fresh- water baths : 

1 . A mechanical f rottement of the skin during and after the bath 
is necessary to bring about a complete reaction. 

2. Many patients cannot stand the first shock of the cold water. 

3. The effect of the bath lasts but a short time. 

4. The increased tissue metabolism is not so great as in other 
baths. 

We can substitute for the thermal and mechanical stimuli 
chemical stimuli, and can likewise overcome the shock of the cold 
water, if the bath contain chemical ingredients which exert a 
frottement of the entire periphery. Through varying proportions 
of the chemical ingredients we can regulate the strength of the 
stimulus. We can, in a bath of indifferent temperature, without 



METHODS EMPLOYED IN MEDICAL TREATMENT 1 23 

shock in this way obtain the same and more lasting stimuli than 
by thermal means, and can cause by chemical combinations a 
more decided increase in the processes of oxidation. We are able 
by such baths to bring about a lasting protection and rest to the 
heart and an improved state of the circulation. An important 
element is the ability to bring about a decided and increased re- 
sorption of broken-down tissue products. 

The addition of salt is one of the means of accomplishing this 
purpose. If five to ten pounds of salt be added to a full bath, 
such a bath can be taken at a lower temperature because of the 
chemical stimulation of the salt. An added advantage is the 
increased oxidation produced by the addition of the sodium 
chlorid, chemical tests having shown that oxidation is increased by 
this means. Zuntz found that in a 3 per cent, saline bath there 
was an increase of oxidation as compared with a fresh water bath, 
so that 15 per cent, more oxygen was used and 25 per cent, more 
CO 2 was given off. If to a bath containing salt, calcium chlorid 
in amounts varying from four to ten ounces be added, the baths 
can be taken at a still lower temperature, because the calcium 
chlorid by its peripheral chemical stimulation aids in the produc- 
tion of a reaction and brings the circulating blood still more actively 
to the surface of the body. Further chemical tests have shown 
that the addition of calcium chlorid to a bath has a marked action 
in increasing tissue metabolism, and that this action is exerted 
specifically in the breaking down of old tissues, such as the end- 
results of various inflammations, and, likewise, such as are in- 
cluded under rheumatic and gouty deposits. 

Agents which, like the saline bath, bring about increased metabo- 
lism are: (1) Sea air, which, however, diminishes the amount of 
phosphoric acid excreted and stimulates the nervous system con- 
stantly without a decided or permanent effect upon the circulation. 
(2) Physical exercise, which, however, demands the increased use 
of energy, increases the amount of phosphoric acid excreted, and 
is decidedly contraindicated in inflammatory pelvic conditions. 

Simple rest causes no increased tissue change, has constitution- 
ally no effect on the general tone, rests the nervous system, but is 
accompanied by no stimulating action on the same. 

If to a bath containing salt and calcium chlorid, carbonic acid 



124 MEDICAL GYNECOLOGY 

gas be added, we have what is called a Nauheim bath, i. e., a 
carbonated saline bath. 

A personal study of the baths at Nauheim, and an observation 
of their action in cardiac affections, showed the marked effect 
exerted by them in dilating the peripheral capillaries, in slowing 
the pulse-rate, in relieving the heart by bringing to the surface of 
the body blood so frequently stagnated in the various internal 
organs, and in producing an equal and even circulation throughout 
the various portions of the body. A further point of interest con- 
sisted in the observation of the marvelous action of the baths in 
cases of locomotor ataxia. I was privileged to observe several 
patients, at first totally unable to stand, who, after a course of these 
baths, were able to walk about, even though with the characteristic 
gait. In quoting the action of the baths in cardiac affections and 
in cases of locomotor ataxia, I simply call to mind the two essential 
advantages gained by their administration: (i) a strengthening 
of the heart and an equal distribution of the blood-supply to various 
parts of the body and to the periphery; (2) a most remarkable 
stimulation of the central nervous system and of the trophic centers. 

My views were originally expressed in the "Medical Record" 
of November 24, 1900, in an article entitled "The Value of Carbo- 
nated Saline Baths in Gynecology." In part my opinion was 
stated as follows : 

"We find in gynecologic practice a very large number of cases 
which, though the symptoms may be severe, deserve conservative 
treatment for the following reasons: (1) Because after a long 
treatment they may be considerably improved; (2) because their 
symptoms as local affections do not justify the risk of operative 
interference; (3) because the desire for future pregnancy is a 
justification for conservatism; (4) because the cases after acute 
inflammations are suited to conservative methods only; (5) because 
such methods are a valuable preliminary to subsequent operation; 
and, finally, (6) because the local affection is very often only a part 
of a generally weakened asthenic physical state. 

"Among these conditions are included certain forms of metritis, 
parametritis, pelveo-peritonitis, salpingitis, hydrosalpinx, pyosal- 
pinx, etc. A large proportion of cases have these affections to a 
slight degree, but combined with them are displacements of the 



METHODS EMPLOYED IN MEDICAL TREATMENT 1 25 

uterus and adnexa with chronic congestion or venous stasis in the 
pelvis, with reflex and constitutional symptoms; not infrequently 
ren mobilis, gastroptosis, and enteroptosis are found coexisting. 
These latter patients often possess a flabbiness and lack of elasticity 
which is by no means the result of the gynecologic condition, so 
that we are compelled to consider the latter as part o) a general 
state. From the gynecologic standpoint we name this condition 
hysteroptosis." 

"It was the frequency with which the cases of hysteroptosis 
came under my observation that influenced me to look to constitu- 
tional treatment for their relief in place of continued local applica- 
tions for these symptoms, among which leukorrhea, pelvic loose- 
ness, and especially backache may be mentioned. The method 
which has the greatest and most rapid effect, and which in certain 
cases seems almost specific, is hydrotherapy, under which we uuder- 
stand both thermal and chemical stimuli. A study of the general 
action of thermal carbonated saline baths confirms me in the belief 
that we have in them an excellent method of treatment for such 
cases, especially to promote the resorption of exudates and inflam- 
mations, and for the relief of congestions. The results obtained 
in the treatment under my own direction in Abel's clinic, Berlin, 
of twenty-one selected cases, with various gynecologic ailments, 
amply justify the acceptance of this method, and future experience 
will suffice to fix the limitations and indications." 

Much has been written of the action of the Nauheim baths in 
valvular cardiac affections and in myocarditis. Relatively little 
has been acknowledged of their value in rheumatism and gouty 
states, and almost nothing, to my knowledge, of their value in 
many perplexing conditions found in gynecology — conditions not 
open to surgical treatment, conditions very little benefited by our 
usual therapeutic measures. In studying the literature concerning 
Nauheim baths, I found that Beneke, in 1857, made most exhaus- 
tive investigations on patients whom he followed closely. He took 
into account the intake of food; he observed and made chemical 
analyses of the urinary excretion and of the excreta; he took into 
consideration variations produced by temperature, and the result of 
his observations showed that the baths exerted a most remarkable 
effect on tissue metabolism. He later established the value of the 



126 MEDICAL GYNECOLOGY 

baths in rheumatism and gouty diseases, claiming that joint exuda- 
tions and inflammations were rapidly removed, and that valvular 
affections of the heart were prevented or reduced to a minimum if 
the baths were given shortly after an attack of acute rheumatism. 

As I use it, a Nauheim bath consists of a tub full of water, con- 
taining sea-salt, calcium chlorid, and carbonic acid gas in varying 
proportions. The various springs at Nauheim contain these 
elements in different proportions. The baths are taken at a tem- 
perature varying from 95 to 8o° F. The duration of the baths 
varies from eight to twenty minutes. The ease with which these 
baths may be arranged at home, in a sanitarium, or in a hospital, 
their splendid action in cases which, as said before, cannot be 
wholly benefited by operation, lead me to call especial attention to 
their therapeutic value. 

The addition of carbonic acid gas to a bath is a most important 
factor, causing a dilatation of the peripheral capillaries and bringing 
the blood still more readily to the surface of the body, thus relieving 
congested areas and taking a strain off the cardiac muscle. A 
further and most important action of the carbonic acid gas is that 
to which Graiipner has called attention, viz., its reflex action upon 
the central nervous system, stimulating the various transmission 
fibers, and the trophic centers in the spinal cord. Some of the 
results of the Nauheim baths include : 

1. A slowing of the pulse-rate. 

2. An increased excretion of urine. 

3. Increased oxidation. 

4. Increased metabolism and a breaking-down of old tissues. 

5. A regulation of the circulation and an even distribution of the 
blood through the various structures of the body. 

6. Increased demand for nutrition. 

7. Building up of healthy tissue. 

8. Resorption of exudates. 

9. The relief of congestion. 

10. Stimulation of the nervous system and the trophic centers. 
The baths should be taken under the observation of a physician, 

for changes in the strengths of the baths, in their temperature and 
in their duration, depend upon the reaction in the individual 
patient and upon the result which is to be produced. The effect 



METHODS EMPLOYED IN MEDICAL TREATMENT 1 27 

upon metabolism and tissue change is brought about, not through 
exertion or through the giving off of reserve energy, but through 
the channels of protection and tissue substitution. This regulated 
and altered tissue change goes on within a certain physiologic 
limit, which should not endanger or overtax the functional energies 
of the body. Over-stimulation is to be avoided, for it readily 
results in nervousness, sleeplessness, loss of appetite, and marked 
languor. Every bath should be followed by a sensation of exhilara- 
tion. There are patients who will stand these baths only when 
of the weakest form. Such patients are normally just about able 
to meet the usual demand of tissue change only by the greatest care 
in the one way of diet, air, and rest, and too great stimulation dis- 
turbs this delicate balance without producing any gain. 

My first experience with the baths was made on a patient suffer- 
ing from marked gonorrheal cellulitis, which so completely sur- 
rounded the pelvic structures that it was impossible to map out 
uterus, tubes, or ovaries. A course of twenty baths so relieved 
this exudation and inflammation that examination showed a freely 
movable uterus, and tubes and ovaries of the character of salpingitis 
or salpingo-oophoritis. Twenty hospital cases were then treated 
by this method. One-half were of an inflammatory nature; 
the other half were cases in whom local pelvic relaxation, uterine 
displacements, as well as abdominal ptoses, were complicated in 
varying degrees by that complex of nervous symptoms to which 
the term neurasthenia is so readily applied. In the inflammatory 
cases the relief of congestion and inflammation was so noticeable 
as to be remarked on examinations made two or three times weekly. 
In the second class of cases there was a stimulation of the general 
nervous system, a marked exhilarating effect on the depressed 
physical and mental state, and a general trophic effect on the in- 
elasticity so noticeably a part of these cases. Further observation 
of the effect of these baths on a series of over one hundred cases in 
private practice has served to still more firmly establish their value 
in my opinion, and I herewith mention the class of cases in which 
aid and benefit frequently may be obtained by the Nauheim bath. 

1. The baths are of value in certain cases of insufficient develop- 
ment of the genitalia, associated with relative amenorrhea and with 
dysmenorrhea, especially if complicated by chlorotic symptoms. 



128 MEDICAL GYNECOLOGY 

The giving of iron and arsenic, as well as ovarin, is an added thera- 
peutic measure of very great potency. 

2. Uterine conditions associated with a lack of tonicity of the 
muscular and vascular structures, such as are found, for instance, 
with uterine catarrhs. The immediate effect can be recognized 
by the large amount of mucus discharged after a bath, which 
result is produced by the increased circulation and increased 
stimulation to contraction on the part of the uterus. Therefore 
the baths are of great value in cases of subinvolution, and in per- 
sistent hyperemia with or without an inflammatory etiology. 

3. Cases of inflammatory metritis and subinvolution fibrosis 
may be benefited so long as no great interstitial hypertrophy has 
taken place. On the other hand, such cases as are associated 
during the climacterium with marked bleedings should be treated 
with care, since an increased blood-supply is liable to produce 
exacerbations of hemorrhage. 

4. A large number of cases of sterility are due to a latent, very 
subacute salpingitis, sometimes with and often without closure of 
the abdominal end of the tube by cobweb peritoneal adhesions. 
We know that cases of salpingitis of that form in which the ab- 
dominal ends are not absolutely closed are cases which may be 
cured. That adhesions may be prevented and the organization 
of adhesions may be avoided by these baths, I believe to be well 
grounded theoretically, and to be proved practically. The Nau- 
heim bath by promoting a normal pelvic circulation, by relieving 
congestion, by toning up the system generally, can cure such .cases 
of salpingitis, and pregnancy may result. The edema of the 
tubal mucosa disappears and the cilia become active. The attain- 
ment of this desired end is aided by very conservative vaginal 
treatment of the cervix, of cervical catarrh, and of cervical erosions. 
Great stress is to be laid on the avoidance of intracervical and 
especially intrauterine treatment of any sort. 

5. A very beneficial action is exerted by the baths in cases of 
inflammatory infiltrations of the pelvic connective tissue. Cases 
of cellulitis, particularly such as occur after labor or abortion, if 
treated before a sclerosis takes place are very much benefited by 
the administration of the baths. If the baths are given after the 
pelvic connective tissue is contracted and sclerosed, the benefit 



METHODS EMPLOYED IN MEDICAL TREATMENT 1 29 

is much less marked. In all inflammatory conditions, after the 
temperature has been reduced to the normal, with or without opera- 
tive measures, the increased blood-supply and the relief of conges- 
tion aid the resistance of the patient in overcoming the .remaining 
inflammatory elements, and tend to restoration to the normal with 
a minimum amount of injury. 

6. An almost specific action of the baths is to be found in those 
cases of local pelvic subinvolution and in cases of general subin- 
volution so frequently associated with gastro-enteroptosis and 
movable kidney. These conditions are most frequently found in 
women who have borne children, but occasionally in certain 
women who are characterized by a general inelasticity, but who 
have not borne children. The baths increase the tonicity of the 
various ligaments related to these pelvic and abdominal ptoses. 
The baths produce an exhilaration temporarily and an increase 
in strength permanently. 

Those cases complicated by hysteroptosis are decidedly benefited. 
The patients gain in strength and weight, the number of red 
blood-cells is greatly increased, appetite improves, and a feeling of 
strength and exhilaration results, such as no treatment can accom- 
plish in the same time. In addition, the local symptoms and, what 
is more important, the idea that a diseased local state exists, dis- 
appear. Here, too, the addition of iron, arsenic, and ovarin is a 
valuable therapeutic adjunct. 

7. There are numerous cases in whom it is desirable before 
operation to restore to the normal the circulation in the pelvis and 
to reduce to the greatest possible degree the amount of associated 
exudation. I refer to cases of pyosalpinx, and especially to cases 
of salpingitis. Here a course of baths given before the operation 
aids permanent convalescence of the patient and has a tendency 
to prevent the occurrence of further adhesions. In other cases a 
course of baths administered after the operation furthers the con- 
valescence and aids in the resorption of those stump exudates 
which so frequently mar the permanent valuable results of the 
operative procedure. 

8. An unrecognized but most valuable field for the administra- 
tion of the baths is found in the post-partum treatment of women. 
In my own practice, so soon as mothers are able to walk about, at 

9 



130 MEDICAL GYNECOLOGY 

some period in the third week, a course of these baths is given to 
aid the involution of the pelvic organs, to assist in the restoration 
of pelvic and general tonicity, to stimulate the nervous system, 
and to aid the secretory function of the breasts. I am sure that 
with this aid patients suffer less from loose abdominal walls, 
acquired displacements of the uterus, hysteroptosis, and physical 
and mental asthenia. I find that patients at the end of five to 
six weeks are almost restored to their normal previous condition 
of elasticity and well-being. 

9. Certain cases of obesity, especially such as are accompanied 
by a diminution in their regular menstrual flow, are benefited by a 
course of these baths. Not infrequently the patients lose weight, 
especially on a diet rich in nitrogenous elements and poor in the 
starchy components. Here, again, the addition of iron, arsenic,, 
and ovarin aids in the desired result. 

10. A further and most valuable field for the use of the baths is to 
be found in the treatment of neurasthenic states, and especially 
those noted in the climacteric period. Here the nervous accom- 
paniments of the " change of life" are often a source of annoyance 
and misery to the patient and her family. In those cases not com- 
plicated by climacteric hemorrhages, I am most enthusiastic about 
the results to be gained by a course of Nauheim baths. The asthenic 
physical condition, the mental depression, the irritability, the ner- 
vousness, and especially the sleeplessness, are often relieved to a 
great extent by a judicious use of these carbonated saline baths. 
If with the baths a thorough course of massage is given, and if at 
the same time ovarin is administered, with or without iron and ar- 
senic, the results in many instances are nothing short of astounding. 

1 1 . Though not strictly in the field of gynecology, I must again 
mention the valuable action of the Nauheim bath in many cases 
of rheumatism and gout. Many gynecologic patients suffer from 
such states, and have gouty or rheumatic nodules in various parts 
of the body, causing severe pain in various nerves, and causing 
attacks of marked occipital headache and pain along the vertebra,, 
often associated with mild or severe attacks of migraine or pseudo- 
migraine. Here Nauheim baths plus massage or the nodules are often 
productive of marked relief from the annoyances of this diathesis. 

These classes comprise, as can be seen, instances of almost 
daily occurrence in general as well as in gynecologic practice. 



METHODS EMPLOYED IN MEDICAL TREATMENT 131 

Among them are cases which operation does not benefit. Among 
them are cases in which local and general therapy often fail us. 
There are other cases which frequently seek relief at the hands of 
the neurologist. Many of the latter class, however, evidence symp- 
toms which occur in women because they are women; i. e., they 
are cases suffering from symptoms related in a greater or lesser 
degree to the specific functions of the genital organs, and as such 
are strictly gynecologic in their nature. 

Baths when begun contain 3 to 5 pounds of sea-salt, 2 to 4 ounces 
calcium chlorid, and J box of Triton salts. In sensitive cases 
the Triton salts, which furnish the carbonic acid gas, are omitted 
from the first few baths. The water is of a temperature of 95 F. 
and the duration of the bath is eight minutes. The patient lies 
quietly in the bath. Difficulty in breathing is often noted for the 
first minute or two. At the expiration of the stated time the body 
is dried gently, preferably with warm towels, and the patient 
then lies down in bed for one hour, first taking a cup of hot milk 
or weak tea. At the expiration of this hour the patient may resume 
her daily vocation, being careful to avoid great exertion of any 
sort. Baths are best taken in the morning, at least two hours 
after a meal. The baths are taken three days in succession; 
then comes an interval day on which no bath is taken ; then three 
more baths are taken; then comes another interval day, and so 
on until about twenty baths have been administered. No baths, 
of course, are given during menstruation. Each set of three 
baths is made a little stronger by the addition of a little more salt, 
a little more calcium chlorid, and more of the Triton salts, but only 
if patients stand the baths well. The last three to six baths con- 
tain 8 to 10 pounds of sea-salt, 8 to 10 ounces of calcium chlorid, 
one box and a half of Triton salts. The temperature by this 
time has been reduced to 85 F. and in some instances to 8o°. 
The lowering of the temperature depends upon the manner in 
which the patient bears the change in temperature. No patient 
should leave the bath feeling cold or chilly. The slight sense of 
chill noted on getting into bed after a bath disappears on drinking 
the hot milk or tea. The last baths should have a duration of 
eighteen to twenty minutes. The beneficial effects of these baths 
are very much enhanced by a subsequent change of air for from 



132 MEDICAL GYNECOLOGY 

two to four weeks at an altitude of 1000 to 2000 feet. In almost 
all cases, and especially in cardiac cases, the routine administra- 
tion of digalen for several weeks after a course of baths produces 
an extremely beneficial tonic effect. 

A modification of these baths can be used in cases in which the 
effect desired is purely pelvic, as in mild subacute inflammations 
and in cases in which the full bath is not feasible through lack of 
accommodation or where the expense of the full baths cannot be 
borne. I refer to sitz-baths which contain enough water to cover 
the pelvis up to the umbilicus when the patient is in a sitting 
position. Such a bath, containing 3 to 5 pounds of sea-salt and 3 
to 6 ounces of calcium chlorid, at temperatures from 95 down to 
85 F., and of a duration of ten to twenty minutes, is followed by 
very good results in the way of influencing the pelvic circulation 
and relieving congestion and the slighter degrees of pain. The 
condition of patients should be noted during a course of baths. 
Too much stimulation by the carbonic acid gas may cause palpi- 
tation, restlessness, and weakness. The baths should then be 
stopped for a few days, and on their renewal should be begun of a 
less strong character as concerns all the ingredients used or should 
be given every other day. Nervous individuals must be given 
graded treatment, and in these, as in anemic cases, progress must 
be made slowly, for, as Graiipner says, these are cases in which the 
entire energy of the body is consumed in preserving a balance be- 
tween nutrition and the force used in the performance of the most 
necessary body functions, so that the slightest degree of overstimu- 
lation is injurious. 

I believe that the results obtained justify me in claiming for the 
carbonated saline baths a power of resorption too valuable to be 
underestimated. The method, in addition, benefits the general 
state to a decided degree and increases the natural and effective 
functions of the body, tones up those pelvic structures which depend 
so decidedly for their elasticity and blood-supply on the condition 
of the circulatory system and of the body in general, stimulates the 
central nervous system and the trophic centers, and produces both 
temporarily and permanently a state of exhilaration and well-being. 

Marked arteriosclerosis, and nephritis are considered contrain- 
dications. 



AMENORRHEA 

Knauer transplanted the ovaries of rabbits and dogs between 
the fascias of the abdominal wall and into the mesometrium, being 
careful to remove absolutely every bit of ovarian structure. In 
the abdomen he fastened the ovary with two sutures between 
folds of peritoneum, the ovaries being then nourished through 
endosmosis or through plasmatic circulation. New vessels grew 
into the ovarian tissue and furnished its subsequent support; 
this change began as early as the fourth day. Examination at 
various periods showed that a small part of each ovary usually 
degenerated, and new connective tissue appeared in the place of 
the lost cells. In all cases in which a complete degeneration of 
the ovary occurred, atrophy of the breasts and of the genitalia 
was found. The muscle of the uterus was atrophied, the inter- 
muscular connective tissue was increased, the mucous membrane 
was atrophied — changes like those which occurred after double 
castration. Retention of function on the part of the transplanted 
ovaries was always evidenced by the growth of follicles in a 
normal manner, by the ripening of the follicles, and by the discharge 
of the ova. In all such cases the normal character of the breasts, 
of the uterus, and of the genitalia was preserved, and in the younger 
animals all these organs underwent a natural development. 

Knauer' s results proved that the preservation to the organism 
of functionating ovaries preserved the breasts, the genital organs, 
and the sexual instinct. This result occurs through the absorp- 
tion into the circulation of ovarian secretion. This internal 
secretion reaches the blood through the lymph-channels. The 
trophic function which the ovary exerts upon the body stands in 
closest relation to its ability to form ripe ova. Ovarian tissue 
which has ceased to develop ripe ova has lost its secretory function. 

The normal human ovary produces and expels ova capable of 
being fecundated. Ovulation, as a rule, occurs from four to 
eight days before menstruation, but it may occur at other periods, 

1 33 



134 MEDICAL GYNECOLOGY 

as ripe ova, practically speaking, may be present at almost any 
time. In the intermenstrual period follicles ready to burst are 
present. Ovulation may occur during pregnancy. The rela- 
tively frequent occurrence of pregnancy during the temporary 
amenorrhea of lactation is a proof of ovulation during this time. 

Ovulation and menstruation are both the result of the secreting 
function of the ovary and are not related as regards cause and 
effect. Menstruation occurs only after the ovary is capable of 
producing ripe ova. 

Ovulation and menstruation are evidences of the functional 
capability of the ovary. Ovulation may occur without menstrua- 
tion, but the latter never without the former. We have here an 
evidence that functional secretory activity of the ovary is necessary 
to stimulate the mucous membrane of the uterus to its periodic 
changes. The part which the ovaries play in the development of 
the body, the effect of their influence upon the breasts and the gen- 
ital tract, at puberty, before each menstrual period, at the meno- 
pause, and after castration, are proofs of their secreting power. 
The experiments of Knauer and others show that it is simply the 
presence of ovulating ovaries and the absorption of their secretion 
which are of importance to the body, and that their action upon the 
uterus is in nowise reflex in character since, when removed and im- 
planted elsewhere, and in this way loosened from direct connection 
with nerve-plexuses and the nervous system, every sexual pecu- 
liarity is absolutely preserved. 

Menstruation is a periodic loss of blood from the lining of the 
uterus. Menstruation implies a regular congestion produced by 
the ovaries acting on a uterus of such a structure and containing 
such a lining that the congestion is relieved by the bursting of 
capillaries and the outflow of blood. Menstruation implies func- 
tionating ovaries, a developed uterus, a normal or fairly normal 
state of the blood, and an open unobstructed canal from the uterus 
through the cervix, vagina, hymen, and vulva. 

Definition. — Amenorrhea means an absence, a too late begin- 
ning, a temporary cessation, or a too early permanent cessation of 
the menstrual function. It is, therefore, of two forms. The 
first or primary form is that in which menstruation is not yet 
established; the second is the secondary form, in which men- 



AMENORRHEA 1 35 

struation ceases after having once been regularly evidenced, 
whether the cessation is temporary and lasts for months or years, 
or whether it is permanent, as in early menopause or climacterium 
praecox. Amenorrhea may be relative or absolute. Relative 
amenorrhea implies that menstruation is extremely slight, while 
absolute amenorrhea means that no blood is lost at all. 

Primary Uterine Hypoplasia. — There may be an absence 
of the uterus, with or without the presence of ovaries, for which 
embryologic causes may be at fault. General hypoplasia of the 
vascular system is a cause of insufficient development of the geni- 
talia. Forms of uterine subdevelopment occur, associated with 
general hypoplasia. Winckel has shown that, in the develop- 
ment of the uterus and tubes, the situation of the Wolffian body 
close to the ducts of Muller may influence, to a very great de- 
gree, their growth, and is a frequent cause of malformation. 
The early completion of the Wolffian bodies, their opening into 
the sinus urogenitalis, the growth of the Miiller's ducts along 
the Wolffian, and their crossing at that spot where the union of 
Miiller's ducts finds its upper limit, are anatomic embryologic 
factors easily recognized as causes of uterine maldevelopment and 
hypoplasia. Further, the origin of the ligamentum ileo-genitale 
rotundum at this upper limit, its close union with the ducts of 
Muller, the fact that its line of development in a measure opposes 
the union of the ducts, in addition to tension, pressure, and torsion 
exerted by the neighboring organs, such as the Wolffian bodies, 
the bladder, the ureters, the vessels and nerves of the uterus and 
rectum, are important factors influencing the development of the 
uterus. In addition, Winckel recognizes the occurrence of ab- 
normal cells in the septum between the ducts of Muller, and general 
hypoplasia of the vessel system, as additional causes of maldevelop- 
ment. 

Secondary Uterine Hypoplasia. — Aside from the embryolo- 
gic causes here mentioned, the forms associated with general 
hypoplasia and secondary atrophy resulting from constitutional 
diseases, we recognize in the ovary and its secretion the factor 
which governs the development of the uterus, the genitalia, and 
the breasts, and the factor which is concerned in the preservation 
of these organs and the regulation of menstruation. In castrating 



136 MEDICAL GYNECOLOGY 

young guinea-pigs the breasts are later found to be one-fourth 
the normal size, the genitalia are small, the vulva is one-third 
smaller than normal; the uterus is as small as at birth, showing 
very slight development of the muscle and endometrium, and 
containing no ciliated cells. The breasts show no glandular 
tissue, the mammillae are hypoplastic. 

Poorly developed ovaries are the result of failure of develop- 
ment of the body in general, or represent a failure of development 
of the ovary itself through embryonal disturbances. Diseases of 
children, such as scarlatina, measles, mumps, diphtheria, typhoid, 
etc., are not rarely the cause of eruptive, hemorrhagic, or necrotic 
involvements of the vagina, uterus, tubes, and ovaries. The 
ovarian or uterine involvement may be of such a degree of severity 
as to interfere with the development of the uterus and of the ovaries. 
If the energy and development of the ovaries is interfered with, 
it must of necessity result in an under-development or hypoplasia 
of the uterus and tubes. We recognize in the ovary and its secre- 
tion the factor which governs the development of the uterus, the 
genitalia, and the breasts, and the factor which is concerned in the 
preservation of these organs and in the regulation of menstruation. 
The absence of ovaries, a poor development of these glands, an 
insufficient secretion of ovarian substance, or a diversion of ovarian 
secretion to other organs of the body, always causes a total or partial 
or relative failure of uterine development, or causes uterine atrophy. 
There may be a uterus fcetalis, a uterus infantilis, or a hypoplastic 
uterus. 

Hypoplasia is of two kinds — concentric, the severe form; and 
eccentric, usually temporary. It may be taken for granted, if 
the ovaries on examination are found to be present and large 
and if molimina menstrualia occur, that the ovaries are not at 
fault, but that the condition is due to embryonal causes mentioned 
by Winckel, or to a general hypoplasia or to direct involvement of 
the uterus by constitutional diseases. 

Amenorrhea of Chlorosis. — Amenorrhea is frequently a 
symptom of chlorosis. It seems to be related to a temporary 
functional inactivity on the part of the ovaries. Chlorosis is an 
illness occurring exclusively in girls, most frequently during the 
years of development and the years immediately following, and 



AMENORRHEA 137 

showing a tendency to recur. It develops spontaneously without 
evident cause, and has no connection with conditions relating 
solely to nutrition, since its occurrence among the better classes 
is very frequent. It affects directly only the condition of the blood, 
without causing constitutional degeneration and without great 
injury to the general nutrition. No theory with regard to chlorosis 
which leaves out of consideration its occurrence in girls only, at 
the time of, or in connection with, sexual development deserves 
attention. It occurs most frequently between the fourteenth and 
twentieth years. According to Niemeyer, such cases as occur for 
the first time after the twenty-fourth year are almost never chlorosis. 

Von Noorden believes the stimulation which the ovary exerts 
upon the blood-forming centers to be one of its important functions. 
This action is not exerted reflexly, but through the channels of 
circulation by means of the ovarian secretion. In chlorosis there 
is often associated a poor development of the genitalia. The pelvis 
in a certain proportion of cases is of the child's type; in others 
there is poor development of the external genitalia, or a uterus 
infantilis, small ovaries, poorly developed breasts, etc. Seventy- 
four per cent, have failure of genital development of one form or 
another. Among non-chlorotics these conditions are found in 
only 20 per cent. Menstruation is, as a rule, disturbed. During 
the chlorosis there is a very frequently absolute or relative amenor- 
rhea. Those affected with menorrhagia always show a decided 
change in the mucosa. In all, 77 per cent, show a weakening of 
the menstrual function. 

Amenorrhea of Obesity. — In the case of poorly developed 
ovaries menstruation, if present, is often irregular and weak, but 
may eventually become well established or may cease. Although 
these persons may be well developed, yet they may show poorly 
developed genitalia. In connection with small ovaries is found a 
small uterus, the breasts being well developed but containing 
little glandular tissue. There is a tendency to fat, which distin- 
guishes these individuals from those with well-developed genitalia. 

Amenorrhea is not infrequently associated with obesity or 
lipomatosis universalis. In such cases a small under-developed 
uterus may be found. i\s a matter of fact, in all these cases obesity 
is partly the result of the failure of sufficient ovarian secretion. 



138 MEDICAL GYNECOLOGY 

The amenorrhea and the uterine hypoplasia are evidence of this 
failure. Coincident with failure of ovarian activity is a probable 
diminution in the activity of the thryoid gland. The resulting 
diminution in metabolism produces the obesity. 

Vicarious Menstruation. — The constitutional element in the 
process of menstruation sometimes results in the occurrence of 
vicarious menstruation. Under this designation we consider 
bleedings occurring at regular intervals in a patient suffering from 
uterine amenorrhea. The most frequent spot for this bleeding is 
the nose, usually the lower turbinated bones. 

Some cases may be due to uterus rudimentarius, with or without 
the absence of the adnexa of one side. The uterus is small and 
may possess no cavity. Such cases and cases with vaginal defects 
may have vicarious menstruation from the nose at regular intervals 
for months. The mammae and external genitalia are small; 
the patients may suffer from molimina menstrualia every three 
or four weeks for periods of several days. Eventually severe pain 
is experienced, constantly associated with nausea and vomiting. 
Severe molimina menstrualia, sickness of the stomach, and rectal 
bleedings may furnish the indications for operation. Since no 
bleeding takes place from the endometrium, the ovarian secretion 
through cumulative action is responsible for the severe pain. After 
castration all the annoying symptoms disappear. 

Very young children with well-developed pubis and breasts 
have suffered from periodic bleedings of the nose. Older well 
developed girls may suffer from regular bleedings from the nose, 
which stop, however, when real menstruation begins. In rare 
cases there are nose bleedings at regular intervals, which stop dur- 
ing pregnancy, only to begin afterward, and after a continuation 
of several months cease again on the occurrence of a second preg- 
nancy. Bleedings have been described as occurring regularly 
from other mucous membranes, the trachea, the lungs, and the 
stomach. In the latter instance the bleedings were not always 
associated with vomiting, the blood being usually found in the 
feces. In other cases there are bleedings into the thyroid gland. 
In cases with poorly developed uteri these bleedings disappear 
when the uterus begins to functionate properly. 

Amenorrhea of Atresia. — Amenorrhea is due to a primary 



AMENORRHEA 1 39 

constitutional or to a primary local cause. The latter is frequently 
overlooked. 

An atresia may involve the hymen or the vagina. This condi- 
tion has been generally viewed as congenital. The investigations 
of Neugebaur, however, show that among the reported cases of 
stenosis or atresia one-third are congenital and two-thirds are 
acquired. The investigations of Nagel and of Veit show that an 
atresia vaginae, when the uterine canal is normal, is usually an 
acquired lesion. When there is a maldevelopment of the vagina 
and a congenital absence of its lumen, then the uterus is also found 
to be maldeveloped and two-horned. Piering divided the causes 
of acquired stenosis and atresia into traumatic, inflammatory, 
chemical, and thermal. 

In children various degrees of atresia, stenosis, and changes in 
the hymen may occur as congenital alternations or as a sequence 
of gonorrhea, of the milder forms of vulvovaginitis, or with and 
after the various infectious diseases, most frequently after typhoid 
fever and scarlatina. Any irritation, as enuresis, may cause ex- 
coriation with a conglutination of the hymen. Such conditions 
often obtain in the newly born and are not recognized. A conglu- 
tination may occur through the excessive size of the hymen and 
constant rubbing. A congenital conglutination of the hymen 
often breaks spontaneously, but, if acquired, is tenser because of 
the union of thicker hymen folds. Weak and anemic children 
are more disposed to milder forms of vulvovaginitis than other 
children. The presence of milder forms of vulvovaginitis is often 
overlooked, while the failure of treatment in other cases is likewise 
a responsible factor in producing future annoyances. In infec- 
tious diseases there is often a colpitis adhesiva without symptoms. 

The lesions produced by infectious diseases in children include 
vulvovaginitis. The first menstruation with acute infectious 
diseases, especially if amenorrhea follows later, is often due to an 
affection of the vulva or vagina accompanied by a loss of epithe- 
lium, by bleeding, by the presence of ulcers, and easily by subse- 
quent adhesions. The so-called menstruatio praecox is often 
only such a vulvovaginitis. Scarlatina especially may cause throm- 
botic necrotic processes in the vagina. We know that various 
forms of atresia may occur in adults, even in multipara?, as a result 



140 MEDICAL GYNECOLOGY 

of a colpitis adhesiva or as a result of ulcerations accompanying 
fluor, or leukorrhea of gonorrheal origin, if no menstruation or 
coitus take place, and that too without ulcerations and without 
annoying preliminary symptoms. 

Some of the results of atresia are more far-reaching than gener- 
ally known. The occurrence of a hematocolpos with an atresia 
can be readily understood. The occurrence of a hematosalpinx, 
however, is one not so easy of comprehension. This condition, in 
a large proportion of cases, is of a dangerous character. Scarlatina, 
and especially gonorrhea, produce local, often neglected affections 
which cause atresia and also a salpingitis with closure of the tubes. 
Typhoid fever, scarlatina, and measles may produce, without 
symptoms, an atresia, and the affection may extend through the 
cervix and uterus into the tubes, with closure of the latter. 

Diagnosis. — If no menstruation has taken place up to the six- 
teenth year, subdevelopment of the body, hypoplasia of the uterus 
or ovaries, or chlorosis or obesity must be taken into consideration. 
If no menstruation takes place up to the eighteenth or nineteenth 
year, an atresia of the hymen or vagina is one of the possibilities. 
Attention is rarely called to this condition in girls under sixteen 
years of age. When observed, it is usually noted between the 
eighteenth and the nineteenth years, because of the pain that is 
often felt at regular intervals. In other words, the menstrual 
function is carried out, but the exit of blood is prevented by the 
atresia. If examination excludes this involvement, which is some- 
times congenital, but more frequently acquired as a result of 
vulvovaginitis due to the infectious diseases of childhood or to 
gonorrhea, either failure of development of the genitalia is present 
or else under-development of the ovaries, uterus, or both is to be 
found; that is, we are dealing with some form of hypoplasia. 
Degrees vary between absence of uterus, uterus fcetalis, uterus 
infantilis, and hypoplastic uterus. It is important to measure a 
small hypoplastic uterus when made out by bimanual examination. 
A uterus may be small and yet the sound may show the cavity to 
be of normal length, which speaks then for a thin muscular wall. 
If the uterus is small and the sound shows the cavity to be shorter 
than normal, this form of hypoplasia is of profounder meaning. 
Diagnosis and prognosis depend on the character of molimina 



AMENORRHEA 141 

menstrualia. Molimina menstrualia comprise the pain and sense 
of weight felt in the pelvis and back, and sometimes in the region 
of the ovaries, at regular four- weekly intervals. If there are slight 
or no menstrual molimina, the blame for the amenorrhea rests 
wholly or in part with the ovaries. If menstrual molimina occur, 
the ovaries evidently functionate and produce a periodic conges- 
tion, but the uterus is then of such a size and character that the 
exit of blood does not occur. Bimanual examination made through 
the rectum with the aid of a catheter in the bladder is sufficient 
to show the existence of a uterus and to demonstrate its size. If 
there is amenorrhea, or if in place of the normal menstruation 
vicarious hemorrhage occurs (urethra, rectum, lungs, stomach, 
mouth, nose, and eyes), it is necessary to think of an atresia of 
the genital canal. If an atresia is present, it is possible that, as 
a result of hemorrhage into the tube, a hematosalpinx is also 
present. 

Secondary Amenorrhea 

Amenorrhea may occur after regular menstruation has once been 
established and is due to altered blood state, altered metabolism, 
altered ovaries and uterus, or to pregnancy or lactation. 

Amenorrhea Due to Blood States. — Infectious diseases, by 
lowering the vitality of an individual and causing an anemic 
state, may be the responsible factor for amenorrhea. It is noted 
that after typhoid fever, scarlatina, etc., menstruation may cease 
for varying periods of from three to six months or more. In such 
cases a newly formed atresia of the vagina must be excluded, for 
we know that ulcerative and degenerative changes may be pro- 
duced in the genital mucosa by infectious diseases. Beginning 
pulmonary tuberculosis is also a cause of amenorrhea, and the 
latter is frequently one of the very first symptoms. The differen- 
tial diagnosis from chlorosis must be made. Acquired or secon- 
dary amenorrhea also results from involvement of the blood state 
in chlorosis, or leukemia. In the former we are dealing with a 
disease usually present during the developmental and adolescent 
period of life. It is a condition which usually occurs between the 
fourteenth and twentieth years and almost never occurs for the first 
time after the twenty-fourth year. Chlorosis is a disease which is 



142 MEDICAL GYNECOLOGY 

almost never found in men. For these reasons the amenorrhea of 
chlorosis probably bears some relation to the secretory activity of 
the genital glands. 

Amenorrhea Due to Involvement of the Ductless Glands. — 
Involvement of the various ductless glands is not a rare cause of 
amenorrhea. Cessation of menstruation may occur with Addi- 
son's disease, with acromegaly, and especially with myxedema 
and Basedow's disease. This latter disease is most frequent in 
women, and presumably so because of the delicate balance which 
exists between the ovaries on the one hand and the thyroid gland 
on the other. Given, then, a hypersecretion of the thyroid, it is 
only natural to reason that the function of the ovaries is either 
primarily or secondarily inhibited. The thyroid and ovarian 
secretions are to a certain extent antagonistic. In myxedema, on 
the other hand, we have a diminution of thyroid function, and 
perhaps a parallel diminution of the ovarian secretion. Myxedema 
produces such an alteration in tissue metabolism as to naturally 
affect the activity of the various glandular organs, among which 
the ovaries and the uterus are of importance. 

Amenorrhea Due to Ovarian Atrophy. — Acute infectious 
diseases act on the ovaries, in some instances producing ovarian 
and uterine atrophy. Marked involvement of the secretory ac- 
tivity of the ovaries results in uterine atrophy. Such ovarian and 
uterine atrophy may also occur as the result of puerperal fever. 
Exudates about the uterus, too, may interfere with its blood-supply 
and result in atrophy of the uterus. 

While not of frequent occurrence, diabetes may be responsible 
for the occurrence of amenorrhea, by causing atrophy of the ovaries 
and then of the uterus. Another cause of ovarian atrophy with 
resulting amenorrhea, and one which is not generally known, is 
the prolonged use of opium. On the authority of Olshausen, it 
is an influential cause in the production of ovarian secretory inac- 
tivity and structural atrophy. 

Climacterium Praecox. — Menopause occurs likewise in younger 
women, and is due to an early cessation of ovulation and 
functional activity on the part of the ovary, and is therefore an 
early senescence. Such a climacterium praecox usually implies 
an early atrophy of the uterine genitalia, often going hand in hand 



AMENORRHEA 1 43 

with increasing obesity. In some instances ovulation may con- 
tinue. 

At and after puberty we judge the vitality of the ovary by its 
ability to bring its ova to a stage which may be called ripe. For 
the expulsion of an ovum from the Graafian follicle, a gradual 
increase in size of the follicle takes place, depending partly on an 
increase in the amount of the liquor folliculi. The opening which 
serves as an outlet for the ovum is probably the result of the reaction 
or chemical effect produced by a normal ripe ovum. In those 
cases of young children with well-developed breasts and genitalia 
in whom menstruation begins, there is an unusually strong develop- 
ment of the body, and the ova as well as the follicles differ in no 
way from those found in menstruating adults. In the newly born 
and in children, follicles of the same size and even larger ones 
exist without bursting, the so-called atresic follicles. These ova 
and follicles go through the same stages of development as in the 
case of adults. That they are not capable of fecundation is shown 
by the fact that the ova are only one-half as large as in adults. 
Unbroken, persisting, or atresic follicles may occur at various ages 
in adults. Larger follicles and follicle cysts occur in the ovary 
without opening. In women in whom the follicles do not open, 
but do degenerate, cessation of menstruation may occur as a 
result of the so-called missed ovulations. These facts speak for 
a chemical or enzyme power in only the normal, ripe, energetic ovum. 

Amenorrhea of Obesity. — Relative or absolute amenorrhea 
even before the age of thirty may occur gradually, without marked 
symptoms, often in patients who grow fat. It is probably due to 
early involution of the ovaries, and if absolute is called climac- 
terium praecox. Obesity is viewed by some as the result and by 
others as the cause of the amenorrhea. In this amenorrhea of 
obesity we distinguish two classes : the phlegmatic and the excita- 
ble type. Probably an involvement of the ductless glands is in a 
great measure responsible for this condition. We are concerned 
here mainly with the activity of the ovaries and of the thyroid. 
A diminution in the secretory activity of the ovaries and of the 
thyroid diminishes tissue metabolism, and it is only natural to 
expect as a result thereof accumulation of fat and a gain in weight. 
When the ovarian and thyroid secretions diminish in equal degrees 



144 MEDICAL GYNECOLOGY 

so that the balance between the two is of the same nature as in 
the normal woman, the phlegmatic type of obesity results, and a 
condition in some degree comparable to myxedema is the conse- 
quence. If there is a diminution of ovarian and thyroid activity, 
and the ovarian activity is so diminished that a relative degree of 
thyroid hypersecretion exists, we have, in addition to the increase 
in weight, an excitable condition due to the relative hypersecretion 
of thyroid extract. In other words, we have a condition of excitabil- 
ity much resembling the annoying symptoms often associated 
with the climacterium or with the menopause consequent on double 
oophorectomy. Climacterium praecox, therefore, follows more or 
less the types observed at the menopause, and the obesity may be 
referred to the same cause. 

Amenorrhea of Castration. — Knauer found, after castrating 
rabbits, that the uterus atrophied and that the intermuscular 
connective tissue was increased. Sokoloff castrated dogs and 
found that the uterus, especially the circular layer, became atro- 
phied, the vessels were thickened and their lumen smaller. Jentzer 
and Beuttner, on castrating cows, found an atrophy of the muscle 
and of the glands of the uterus, an increased growth of the connec- 
tive tissue, and changes in the stratum vasculare. 

One year after castration the uterus is atrophied, the endomet- 
rium likewise, the connective tissue is increased. There is atrophy 
of the cervix, an atrophy of the corpus, a sclerosis of the vessels, 
which show a growth of the intima, and an endarteritis obliterans, 
especially in the larger vessels. Few glands are present and the 
connective tissue is increased. After castration, the changes are 
like those occurring at the menopause. The removal of the 
ovaries diminishes the excretion of phosphorus. Less carbonic 
acid is given off and less oxygen is absorbed. The body- 
weight increases. The diminution in the excretion of phos- 
phorus after double oophorectomy explains perhaps the value of 
this operation in osteomalacia. 

Amenorrhea of the Climacterium. — The presence of normal 
ovaries preserves uterine muscular tone. The ovarian secretion 
exerts a trophic stimulation upon the uterus and an influence which 
produces, during the fertile period, those regular painless uterine 
contractions which have the effect of auto-massage upon the uterus 



AMENORRHEA 145 

and which preserve its muscular tone. In ovarian changes at 
the climacterium the muscular wall and the mucosa atrophy 
and periodic pelvic congestions do not take place. At and after 
menopause, as a result of normal involution of the ovaries, the 
uterus undergoes regressive changes, the portio shrinks, the 
corpus atrophies, the connective tissue is increased, the vessels are 
sclerosed, the mucous membrane is thin, flattened, and indurated, 
and we have the so-called senile uterus. 

Amenorrhea of Pregnancy. — Ovarian secretion produces a 
general congestion, most marked in the pelvis and uterus. If this 
secretion be opposed by an added secretion which antagonizes and 
nullifies it, then the menstrual congestion fails to occur. In preg- 
nancy we are dealing with a fecundated ovum. A fecundated 
ovum settles into the decidua by dissolving the cells about 
it and boring a hole for itself whereby it sinks into the decidua. 
This is accomplished by the enzyme products of the fecundated 
ovum. The trophoblast or outer layer of this ovum has a destruc- 
tive action on maternal tissues and is held in check by elements 
contained in the maternal blood. These fetal cells are at all 
periods of gestation given off into the maternal circulation and con- 
stitute a fetal or placental secretion. There exists probably an 
antagonism between the ovarian secretion, on the one hand, and the 
enzymes of the fecundated ovum on the other. Hence in preg- 
nancy we may assume the amenorrhea to be due to the fact that 
the pre-menstrual congestion usually produced by the ovarian 
secretion is nullified by the opposing enzymes of the fecundated egg. 
A curious paradox is furnished by the case of a woman who has 
not menstruated for years except during the first three or four 
months of several successive pregnancies. 

Amenorrhea During Lactation. — Ribbert implanted the 
mamma of a young guinea-pig, with its covering of skin, into a 
cut near the ear. The wound healed, and five months after the 
operation, the animal having borne two young, this mamma secreted 
milk normally, a proof that the connection between the breasts, and 
the ovary and uterus is to be found at least partly through the chan- 
nels of the circulation. 

Goltz cut through the cord of a dog at the level of the first lum- 
bar vertebra, and later saw signs of rut appear. After coitus one 



146 MEDICAL GYNECOLOGY 

dead and two living young were bom. The breasts were well 
developed and lactation and nursing followed the normal course. 
Since these changes, the sexual tendency, and the process of labor 
could not have been excited through the cord, it must be that a 
certain secretion of the ovary, acting through the medium of the 
circulation, gives the stimulus for the exercise of those functions. 

After labor, lactation is probably stimulated in addition by 
the thyroid or some internal secretion. The ovarian secretion 
seems to exert no effect or less action upon the uterus; therefore 
the uterus rarely undergoes its periodic or trophic stimulation. 
Continued nursing causes continued contraction of the uterus. 
Menstruation does not take place and there is a natural tendency 
to trophic changes which end in lactation atrophy of the uterus. 

Lactation Atrophy. — There are cases of amenorrhea which 
persist for varying periods of time, even after nursing is stopped, 
in women who have nursed their children for an unusual number 
of months. As a result of nursing there occurs a uterine atrophy 
which is normal up to a certain degree only. In many women 
bimanual examination and the use of the sound show that the 
uterine atrophy has gone beyond the normal. The atrophy which 
has occurred in the genital sphere may prevent the re- establishment 
of menstruation for varying periods of time. 

Under atrophy of the uterus belong those cases in which the 
uterus was previously normal in size, with a cavity of normal 
length. The changes occurring in lactation atrophy are: (a) Eccen- 
tric, with a cavity of normal size but with a deficiency of muscular 
elements; (b) concentric, with a cavity smaller than normal. 
The former cases are not infrequently associated with small adnexa. 
It may be mentioned that the majority of nursing women who 
have a uterus under the normal size show all the evidence of poor 
nutrition, and especially laxity and flabbiness of the general body 
structures. In "prematurely aged women" lactation is poorly 
borne. It is in these cases that Frommell finds the greatest amount 
of uterine atrophy, and he supposes it to be an evidence that nurs- 
ing deprives the body of a large amount of nutrition. 

Thorne considers lactation atrophy to be a reflex trophoneuro- 
sis, and believes that every nursing amenorrheic woman has a 
hyperinvoluted uterus, without, however, an involvement of the 



AMENORRHEA 



147 



ovaries. He acknowledges the frequency of anemic conditions 
associated therewith, but observes that those cases menstruating 
during nursing show no atrophy of the uterus. This associated 
menstruation is an evidence of sufficient ovarian stimulation, and 
of course the uterus does not atrophy. 

Amenorrhea Due to Curettage. — A very thorough curetting 
of the uterus is not infrequently followed by a temporary or perma- 
nent cessation of the menstrual function through uterine atrophy. 
In some instances there occurs a union of the anterior and posterior 
uterine walls, so that an atresia of the uterus results. In other 
cases a too thorough curetting has produced a rapid involution 
of the ovaries and uterus, but in just what way is not definitely 
known. The same annoying conditions have been noted after a 
too deep cauterization of the uterine cavity by steam by the method 
known as atmocausis. 

Atmocausis. — Czempin reported a case treated by atmocausis 
in which menstruation did not recur and the patient suffered from 
symptoms of climacterium praecox. The uterus was foimd to be 
small and hard, the cervix was obliterated by cicatricial adhesions. 

Weis atmocauterized a nullipara. No menstruation occurred 
and the patient suffered with headache and bleeding from the 
nose. Several months later the uterus was found to be small, 
hard, and shrunken; the cervix was closed by cicatrices and a 
sound could not be passed. Two months later the cervix was 
passable by a sound, but for a distance of only 3 cm. The body 
of the uterus was flat and shrunken. Atmocausis is often purposely 
used with the idea of destroying the endometrium and of causing 
an obliteration of the uterine cavity. (See Atmocausis.) 

Amenorrhea Due to Nervous or Mental Conditions. — A 
change of climate is noted as a cause for temporary cessation of 
menstruation. In other instances shock, psychic excitement, or 
mental disease produce amenorrhea of shorter or longer duration. 
The amenorrhea is probably the result of some alteration of metab- 
olism, and is to be referred in some cases to functional involve- 
ment of some of the ductless glands; among them, the ovaries. 
Koblanck finds that in many cases of amenorrhea masturbation 
is practised. These include married women, many of whom have 
borne children. The duration of the amenorrhea varies from three 



148 MEDICAL GYNECOLOGY 

months to several years. The tendency to masturbation is espe- 
cially strong at the time for menstruation. Attracted by the 
observation of Fleiss, he noted that many disturbances in the 
menstrual function, especially dysmenorrhea, are associated with 
circumscribed swellings of certain nasal areas, namely, the anterior 
end of the lower turbinated bone and the directly opposite area of the 
nasal septum. He found that this was produced by strong sexual 
excitement unaccompanied by the relief resulting from physio- 
logic completion of this state. For the treatment of amenorrhea 
the stopping of the masturbation is a necessary factor. 



THE TREATMENT OF AMENORRHEA 

The treatment of amenorrhea is directed to the cause, and con- 
sists most frequently in improving the general physical condition 
and in producing increased blood-supply and hyperemia in the 
pelvis and uterus. Due regard must be paid to the special diag- 
nosis of those cases dependent on diseases of the ductless glands. 
Basedow's disease and aberrant Basedow's disease demand, in 
addition to special treatment, the use of ovarin and antithyroidin. 
Incipient tuberculosis must be looked for and diagnosed from 
chlorosis. Among younger girls the conditions most frequently met 
with are chlorosis, obesity, and uterine hypoplasia. Chlorosis 
is to be treated by iron, arsenic, ovarin, etc. (See Puberty.) This 
condition of hypoplasia is frequently present in chlorosis and is 
very frequently present with obesity. The condition rights itself 
and menstruation is established in the vast majority of cases by 
methods which aid the natural development of the body and of the 
pelvic organs. Anything which aids this process is to be 
commended. 

fy Ovarin (Merck) gr. iij 

Arsen-hemol gr. iss 

Ferri sulph. exsicc. . •. gr. iij 

Ext. cascara gr. ss 

Ft. tal. caps. no. xxx. 

S. — One t. i. d. p. c. 

1$. Liq. potassii arsenitis oj 

Ferro-mannin o vj 

M. S. — 5ij t. i. d. p. c. 

Open-air exercise is essential; salt baths are valuable, but they 



AMENORRHEA I49 

should not be very warm. The diet should be generous and is 
to be restricted only in the case of very obese patients. In those 
younger unmarried girls in whom menstruation appears late or is 
irregular, the best combination consists of a capsule containing 4 
grains of ferri sulphas, ij grains of arsen-hemol, and 3 grains of 
ovarin, given four times a day for several weeks or months. Drugs 
which have stimulative action on the uterus and which may be 
given for long periods are salicylic acid, 5 grains, three or four 
times a day; and apiol, iv minims in capsules, several times a day. 
When possible, very hot vaginal douches should be ordered and 
continued for weeks. (See Hygiene of Puberty.) 

The treatment of amenorrhea demands the production of a 
flow of blood toward the uterus. This may be done by bimanual 
massage of the uterus, if possible, by sea baths, swimming, and 
exercise. Hot prolonged douches should be used and warm sitz- 
baths (90 to 105 , ten to thirty minutes) and hot foot-baths may 
be given. Short cool sitz-baths, 50 to 65 F., one to five minutes, 
or the ice-bag to the lower vertebrae for one-half hour are effective. 
Carbonic acid gas baths are of value. (See pages 111,122.) In ap- 
propriate instances stimulation of the uterus by the introduction of 
the sound may be carried out two or three times a week. Much 
is claimed for the regular use of electricity, the negative electrode 
being introduced into the uterus, a current of 10 to 20 milliamperes 
being used for five minutes twice a week. Apiol capsules (con- 
taining gr. iv) are given three times daily for amenorrhea, their 
administration being begun one week before each period. When 
the symptoms of menstruation appear, four capsules are to be 
given within a period of four hours. 

Acquired amenorrhea, which is so often noted in many obese 
women from the twenty-fifth year on, is a condition extremely 
difficult to correct. Coincident with obesity there takes place a 
gradual atrophy of the uterus. Treatment directed to the reduc- 
tion of the obesity rarely has any effect on the amenorrhea. In such 
cases ovarin tablets, 5 grains each, four times a day, should be 
administered for months, combined, unless contraindicated, with 
the use of iron and arsenic. The amenorrhea resulting from 
lactation atrophy demands general constitutional stimulative 
treatment, the use of Nauheim baths, hot vaginal douches, and in 



150 MEDICAL GYNECOLOGY 

some cases energetic scarification of the cervix. Electricity, as 
noted above, should be used. In such cases, too, the combination 
of ovarin, iron, and arsenic is of greatest importance. 

The amenorrhea resulting in the form of climacterium praecox, 
sometimes without constitutional symptoms and sometimes with 
constitutional symptoms, likewise demands general constitutional 
treatment. The amenorrhea due to shock or associated with an 
altered mental state should be treated by constitutional methods, 
the treatment belonging to the realm of neurology. 

Masturbation must be stopped. Atresia must be corrected by 
surgical measures. 



DYSMENORRHEA 

In normal menstruation we are concerned primarily with the 
ripening of a Graafian follicle and with the congestion produced 
by the ovarian secretion. As a result of the action of the ovarian 
secretion there occurs a hyperemia in all the pelvic structures which 
is characterized by a dilatation and fullness of the vessels. This 
change is most marked in the uterus. The uterus becomes 
softer and larger, the uterus lining is thicker and markedly con- 
gested with blood, and blood extravasation takes place in the super- 
ficial layers of the mucous membrane. Blood is thrown out into 
the uterine cavity and uterine contractions force it out through 
the cerax. The tubes are also congested during the menstrual 
act, but bleeding from the mucous membrane of the tube very 
rarely takes place. 

The pre-menstrual stage begins eight to ten days before the 
bleeding and gradually increases up to the time when blood is 
first poured out. A painless normal menstruation implies that 
there is normal ripening and bursting of a follicle; that there is 
congestion in a uterine wall which is not inflamed, infiltrated, or 
sclerotic; that the mucous membrane can readily become swollen 
and can take up the blood which is extra vasated ; that the capilla- 
ries and vessels are of normal caliber; that the uterine cavity is 
large enough to permit swelling of the mucous membrane; that 
the menstrual blood flows out readily through the cervix, and that 
the congestion in the various pelvic organs is not opposed or limited 
by inflammation or adhesions. 

A normal menstruation should take place without pain. There 
is naturally a slight feeling of weight in the pelvis with some pres- 
sure and some sensation of weight in the region of the ovaries. 
Every pain occurring during or before menstruation is to be con- 
sidered as dysmenorrhea. 

Definition. — By dysmenorrhea is meant the process of men- 
struation accompanied by pain. It represents no disease, no patho- 
logic entity, but is only a symptom which may be due to various 

151 



152 MEDICAL GYNECOLOGY 

diseases or abnormalities in the genital tract. The diagnosis of 
the cause of dysmenorrhea is extremely difficult in many instances 
because we frequently have no alterations which can be recog- 
nized by palpation. Often the diagnosis depends upon non- 
palpable changes of an organic or nervous nature. In every 
instance anatomic or functional changes must be sought for which 
influence the course of the menstrual process. 

Menstruation is not a process which takes place in the uterus 
and ovaries alone, for the pre-menstrual congestion affects all the 
organs in the pelvis, as well as the central and peripheral nervous 
system, and the various organs of the body dependent on them 
for their nerve-supply. Dysmenorrhea in its broadest meaning 
includes all the disturbances of a physical or mental nature; but 
when strictly considered, concerns only those symptoms which 
play their role in the small pelvis (Winter). 

True dysmenorrhea is concerned with processes which take 
place in the uterus. Uterine dysmenorrhea is in all probability 
often due to small recognized or unrecognized myomata situated 
near the cervix or situated in the wall of the uterus or near the 
mucous membrane. It is frequently due to inflammatory processes 
involving the endometrium and the uterine wall and resulting in a 
large uterus. In a few instances it is due to an acute anteflexion, 
and possibly in some cases to marked retroflexion, either of which 
may produce a great degree of obstruction at the internal os. In 
the majority of cases, however, bimanual examination does not 
divulge the changes which are responsible for the painful menstrua- 
tion. Most cases of uterine dysmenorrhea, then, do not show 
palpable lesions. They are due: (1) to hypoplasia of the uterus;. 
(2) to mechanical or spastic obstruction in the region of the cervix; 
and (3) to inflammatory involvement of the endometrium or the 
uterine wall, without enlargement of the uterus. 

The annoyance felt in uterine dysmenorrhea is, in some cases, 
pain in the back, in other cases pain in both sides, sometimes a 
feeling of pressure in the pelvis, in other cases there is extension 
of pain into the legs, in most cases there are colicky pains in the 
uterine region. The characteristic of these pains is that they are 
intermittent, for the essential element in the production of uterine 
dysmenorrhea is contraction of the uterus. 



DYSMENORRHEA 1 53 

Hypoplasia. — Hypoplasia of the uterus is an extremely frequent 
cause of dysmenorrhea. During the pre-menstrual period, the 
ten days immediately preceding the appearance of blood, the super- 
ficial capillaries become greatly dilated. Serous infiltration of the 
endometrium separates the meshes of the stroma and is accom- 
panied by a gradual but decided dilatation of all blood-vessels 
and lymph-channels. The glands become larger and wider, 
being often filled with secretion. The swelling of the mucous 
membrane, the dilatation of the blood-vessels, the production of 
round cells, and the growth of the superficial layer of the endo- 
metrium produce the so-called decidua menstrualis. The endo- 
metrium is at this period from 5 to 7 mm. in thickness. In hypo- 
plasia the vessels of the uterus and its lining are filled with blood by 
the pre-menstrual congestion, but the vessels are small and do not 
take up the blood readily. The cavity of the uterus is too small to 
permit of a normal swelling of the mucous membrane. Increased 
tension in the small vessels causes tonic contraction or cramp in 
the uterus. The congestion, during the few days before the appear- 
ance of blood, comes to its climax with the greatest of difficulty. 

Hypoplasia is frequently found, especially in young, chlorotic, 
anemic girls with delicate physique, or in obese girls. Dysmenor- 
rhea is generally experienced from the first establishment of men- 
struation, but it does not always develop in this manner, sometimes 
first appearing after menstruation has continued for a year or two, 
when the menstrual congestion gradually becomes greater. There 
is generally a history of late menstruation. The pains begin 
several days before the bleeding, in other words, at the beginning 
of the pre-menstrual congestion, and not infrequently recur at 
various periods during the menstrual time. The slighter the bleed- 
ing, the greater the dysmenorrhea. It almost never occurs for the 
first time after marriage, but, on the contrary, frequently improves 
after marriage, and of course after labor. On examination, the 
diagnosis is aided by the finding of a small uterus, by recto-abdo- 
minal palpation, by vagino-abdominal examination, or by the use 
of the sound. 

Mechanical Dysmenorrhea. — In mechanical dysmenorrhea 
we are concerned with obstruction to the outflow of menstrual 
blood. The period during which blood is thrown out is the men- 



154 MEDICAL GYNECOLOGY 

strual period. The superficial capillaries are greatly dilated, and 
an exit of blood- elements, not dependent on a bursting of the 
capillaries, goes on for several days. The bleeding occurs partly 
through diapedesis and, in strong bleedings, through rhexis. 
There is little or no destruction of the mucosa, only a very slight 
fatty degeneration of the epithelium of the uppermost layer, so 
that in the excreted blood relatively few epithelial cells are found. 
The first stimulus to bleeding is due to contraction of the uterus, 
which at the height of congestion is possibly accompanied by con- 
tractions of the tube. During menstruation the uterus is larger, 
and in the first few days following, likewise soft and flabby. The 
flabbiness lasts longer than the bleeding. A spontaneous dilation 
of the cervical canal takes place and reaches its height on the third 
or fourth day. This dilation takes place without regard to the 
amount of blood discharged, whether the menstruation be painful 
or painless. The blood thrown off is mixed with the mucus of the 
uterus and cervix, and later with the acid secretion of the vagina, 
for this reason coagulating less easily than other blood. Whenever 
the menstruated blood finds obstruction to its outflow through 
the cervix, excessive uterine contractions result. Excessive uterine 
contractions produce uterine colic when the outflow of blood is 
obstructed or rendered difficult. The position of the uterus in a 
few cases is responsible for this obstruction. Acute anteflexions 
are frequently considered the cause of dysmenorrhea, but this 
etiology is by no means so frequent as formerly believed. If the 
cervix and uterus lie parallel, then anteflexion is acute enough to 
constrict the internal os. The greater the bleeding, the greater the 
pain. Retroflexion, however, is only rarely the cause of such an 
obstruction. Obstruction is most frequently produced by stenosis 
of the cervix. Pain may result with total absence of stenosis, 
if a large amount of blood is poured out and if the blood clots and 
is forced out as clots. Such obstruction is rarely caused by the 
external os, however small. Therefore discission is of little value. 
Most frequently we are concerned with the internal os. In some 
cases the obstruction is a real stenosis which barely permits the 
introduction of the smallest probe. In other cases the sound 
enters readily, but obstruction is due to overgrowth of the endo- 
metrium at the cervico- uterine junction, which, when congested 



DYSMENORRHEA 1 5 5 

before menstruation and during menstruation, prevents the 
ready outflow of blood. To such a condition the term cervical 
adenoids may be justly applied. 

Stenosis of the cervix as a cause of dysmenorrhea should be 
diagnosed only if it can be demonstrated by a probe or if it follows 
the symptomatology to be mentioned, or if, after dilation of the 
cervical canal shortly before menstruation, dysmenorrhea ceases. 

Mechanical dysmenorrhea usually depends on cervical changes, 
and for that reason occurs from the first onset of menstruation. 
It sometimes begins, however, after menstruation has taken place 
for a year or two and grows continually worse. Pain begins very 
shortly before the appearance of blood and is due to uterine con- 
tractions caused by the obstruction to the outflow of blood. The 
greater the bleeding, the greater the pain. In some cases only a 
narrow probe can be passed through the internal os. In other 
cases the sound passes, but an obstruction to the outflow of blood is 
furnished by overgrowth of mucosa at the cervico-uterine junction; 
in other words, by cervical adenoids. After a fair amount of blood 
has been passed the pain diminishes or ceases and seldom recurs 
during the subsequent days. When it does recur, it is usually 
followed and relieved by a new flow of blood, and may thus con- 
tinue for three or four days. Dilation three or four days before 
menstruation relieves the pain with stenosis. Such dysmenorrheas 
are cured by labor. If the canal is of normal size and no 
mechanical obstruction is present, the cause of dysmenorrhea is to 
be sought next in inflammatory changes of the endometrium, 
generally of the nature called exudative and interstitial. 

Dysmenorrhea of Inflammatory Endometritis. — If the uterus 
is normally developed and there is no mechanical obstruction, the 
cause of dysmenorrhea may frequently be referred to inflammatory 
changes in the endometrium. These changes are interstitial or 
exudative in their character. We have two forms: The one 
form, which is purely inflammatory and interstitial ; and the other 
form, which is inflammatory and interstitial, but combined with it 
are glandular hypertrophic hyperplastic changes. In these inter- 
stitial forms we may have fluor as a symptom and cervical and 
other evidences of uterine inflammation or uterine catarrh. But 
ofttimes no fluor is present. The uterus is extremely sensitive 



156 MEDICAL GYNECOLOGY 

to the sound and the lining is not infrequently rough when examined 
by this method. This form of dysmenorrhea usually begins 
several days before the bleeding, with pre-menstrual symptoms. 
The bleeding itself is normal with the purely interstitial forms, but 
with the combined interstitial and glandular the amount of blood 
lost is increased. The important characteristic of this form of 
dysmenorrhea is that it is generally acquired. All dysmenorrheas 
which occur first after marriage or which grow worse after marriage 
are almost inevitably inflammatory in their nature. Here pre- 
menstrual and menstrual congestion in a uterus with an inflamed 
lining or wall causes uterine colic. Catarrh is often an important 
symptom. Inflammation may be present without either hemor- 
rhage or fluor. It is evidenced also by "nervous symptoms of 
menstruation." The endometrium is then sensitive to the sound. 
This condition is generally acquired. In many cases there is 
evidence of metritis, salpingitis, and peritonitis. In those cases in 
which dysmenorrhea is present from the establishment of menstrua- 
tion it is to be referred to an infection occurring in childhood or to 
the infectious diseases of childhood. In certain cases the inflam- 
matory changes can be evidenced to the eye, if the lining of the 
uterus is thrown off in the condition known as dysmenorrhea 
membranacea. 

Dysmenorrhea Membranacea. — A rare but typical form is 
dysmenorrhea membranacea. Menstruation is not a process by 
which the mucous lining of the uterus is thrown off, with subse- 
quent regeneration previous to the next menstruation. It is 
simply the excretion of blood from the decidua menstrualis, 
occurring for the simple and sole reason that there is in the uterus 
or tube no fecundated ovum. In dysmenorrhea membranacea 
the whole uterine membrane, or more frequently pieces of endo- 
metrium, are thrown out at menstruation, accompanied by much 
pain. Examination by the microscope shows the typical picture 
of interstitial or interstitial plus exudative inflammation. 

In dysmenorrhea membranacea the whole membrane may be 
thrown out and even the openings at the tubal corners may be 
seen. As a rule, the membrane is thrown out in pieces. The 
microscope gives a typical picture. There is always interstitial 
endometritis; there are scattered groups of round-celled infiltra- 



DYSMENORRHEA 157 

tion. The spaces of the interglandular tissue are filled with a 
finely granular exudate and blood, forming the exudative type. 
Sometimes large cells are present and produce a resemblance to 
decidua. 

Tubal Dysmenorrhea. — Since congestion occurs in all the 
pelvic organs at menstruation, pain may be felt in the ovaries, the 
tubes, the peritoneum, and the connective tissue, or may manifest 
itself as a general nervous alteration if inflammation be present 
in these pelvic structures. 

Tubal dysmenorrhea is due to chronic inflammation of the 
Fallopian tubes and is often associated with adhesions. Here 
the dysmenorrhea simply represents an exacerbation of the pain 
felt at other times. No tubal dysmenorrhea should be diagnosed 
without the discovery' by bimanual examinations of alterations 
of their form, size, or position. The annoyance is one of discom- 
fort and rarely one of marked pain. Dysmenorrhea due to peri- 
toneal or connective-tissue involvement implies an existing inflam- 
mation in the form of chronic peritonitis or chronic parametritis. 
These cases simply represent at the menstrual period an increase 
of the pain more or less constantly associated with the lesions 
themselves. 

Pain due to tubal inflammation is of a gnawing, burning nature 
felt in the side. Actual colics usually come from uterine con- 
traction, though they may be due to tubal contractions. In chronic 
inflammation the pre-menstrual congestion causes pelvic pain, 
and generally the uterus, tubes, and ovaries are affected. 

Ovarian Dysmenorrhea. — Ovarian dysmenorrhea, as a rule, 
is due to chronic inflammation of the ovary, sometimes with severe 
degrees of adnexal disease, very often with mild, almost unrecog- 
nized forms of inflammation. 

In the chronic form of interstitial oophoritis there results the 
formation of connective tissue with sclerosis; the follicles are de- 
stroyed and the stroma shows fibrous connective tissue. It is not 
to be doubted that the infectious diseases of childhood may be 
responsible for such alterations in the structure of the ovaries. 
Other infectious diseases are likewise a cause of structual altera- 
tion. Intraperitoneal conditions are a frequent cause. The 
peritoneal irritation and peritoneal exudation associated with 



158 MEDICAL GYNECOLOGY 

milder or severer degrees of appendicitis or of tuberculosis results 
in infection of the follicles and in interstitial inflammation of the 
ovaries. Upward extension of inflammation from the uterus in 
the gonorrheal infection of children, and in the subacute upward 
extension of gonorrheal or other inflammations in adults, is the 
most frequent cause of ovarian involvement, with or without the 
production of adhesions. In such cases we often have single or 
multiple Graafian follicle cysts or small tubo-ovarian cysts. 

Retention cysts originate, as a rule, in consequence of chronic 
inflammatory changes. Through the resulting hyperemia there 
occurs a serous exudation from the vessels and an effusion of 
serous fluid into the follicles. In advanced cases the greater 
portion of the interstitial tissue may be replaced by cysts. The 
cysts, as a rule, attain the size of a ripe Graafian follicle. The 
lining of the follicles plays only a passive role. Interstitial oophori- 
tis is the most frequent cause of follicle cysts. The ovary contains 
numerous follicles of various sizes. Retention cysts are inflamma- 
tory cysts in which there occurs a "cystic degeneration" of the ovary, 
often associated with visible disease of the tubes and with mild 
adhesions. This gross condition is generally double, but the pain 
is usually unilateral. The entire ovary is distended and its surface 
is irregular. If the condition continues, one follicle may overtop 
the others, may cause them to atrophy, and may result in the 
formation of a large Graafian follicle cyst. 

For the expulsion of an ovum from the Graafian follicle, a gradual 
increase in size of the follicle takes place, depending partly on an 
increase in the amount of the liquor folliculi. The opening which 
serves as an outlet for the ovum is formed partly by the thinning 
of the tunica albuginea by pressure and partly by the chemical or 
enzyme effect produced by the ripe ovum. In the newly born and 
in children follicles of the same size exist without bursting, the 
so-called atresic follicles. The ova are small and unripe, hence 
the follicles do not burst. Unbroken atresic persisting follicles 
may occur at various ages in adults. In women in whom the folli- 
cles do not open but do degenerate as a result of missed ovulation, 
there is a lack of ovarian energy and varying degrees of amenor- 
rhea often occur. At and after puberty we judge the vitality of 
the ovary by its ability to bring its ova to a stage called ripe. 



DYSMENORRHEA 1 59 

Congestion and tension in the ovary accompany the congestion 
of the uterus and pelvic organs which results in menstrual bleed- 
ing. If an ovary functionates and if its ova are ripe ones, then 
any change in the structure of the ovary, in its tunica albuginea, 
or in its nerve-fibers will result in unusual manifestations when 
Graafian follicles increase in size for the expulsion of ova. This 
congestion and tension will be experienced as a severe pain in 
hypersensitive, long-suffering women. Increased tension in the 
ovaries causes swelling of the mucous membrane of the uterus 
and may prolong menstruation. Ovulation occurs from four to 
eight days before menstruation, but it may occur at other periods, 
as ripe follicles ready to burst may be present at any time. 

From inflammatory causes, and also in young girls and women 
without evidences of inflammation, ovarian dysmenorrhea is very 
frequently due to a thick albuginea which makes the breaking of a 
Graafian follicle difficult. No evidences of adhesions are present 
about the ovaries. This pain does not necessarily occur at every 
menstruation. Ofttimes the sensitive ovary can be felt to be 
enlarged before the Graafian follicle which produces the pain 
bursts. 

In ovarian dysmenorrhea there is shooting, boring, pressing pain 
in the region of the ovary, frequently extending out into the hips 
or thighs or up to the ribs. As with any inflammatory condition 
of the uterus and adnexa, this may represent simply exacerbation 
of the pain felt at other periods or on examination, or else the pain 
is felt only before and during menstruation. Nausea is often 
a marked symptom. The ovaries are sensitive and enlarged and 
most frequently not adherent. There are many cases where, 
without palpable inflammatory involvement, severe pain is felt 
in the region of one or both ovaries during menstruation, for the 
etology of which ovarian alteration we may look back to changes 
produced in their structure by the diseases of childhood perhaps. 
(See section on Pain.) 

The diagnosis of ovarian dysmenorrhea implies the finding by 
bimanual examination of palpable changes in an ovary or the 
finding of a sensitive ovary by bimanual manipulation. 

In chronic oophoritis the ovary is rarely as large as a small egg. 
It is sensitive and other inflammatory evidences may be present. 



l6o MEDICAL GYNECOLOGY 

In making the diagnosis of chronic oophoritis, the o\ary may be 
felt to be constantly enlarged and to be painful and sensitive on 
pressure. Care must be taken not to include in this class an ovary 
containing a Graafian follicle about to burst which gives on a 
single bimanual examination the evidences of an enlarged sensitive 
ovary. Repeated examinations must show such an ovary to be 
constantly enlarged. Small cystic degeneration is evidenced by a 
hard, tense feeling or an irregular surface. In the smaller cirrhotic 
conditions of the ovary the cystic consistence is generally lacking. 
Such an ovary is found only on careful bimanual examination. 
It may be situated in the normal location of the ovary, but very 
often it is posterior to the uterus or in the cul-de-sac of Douglas. 
These smaller ovaries are of various sizes and are with or without 
adhesions but may be, nevertheless, structually altered. 

Ovarian Neuralgia. — Olshausen has described what is called 
ovarian neuralgia, in which there are no signs or evidences of in- 
flammation or adhesions. Pain is felt during menstruation 
especially between the twentieth and the thirtieth years. It is 
considered a neuralgia because it begins suddenly, lasts a few 
hours or days, and stops suddenly. By others it is called peri- 
oophoritis or hysteria. It generally implies a structural change 
in the ovary. (See section on Pain.) 

Hyperesthesia of the Endometrium. — There is a form of 
dysmenorrhea in which the uterine lining is extremely sensitive 
to the sound. The internal os is likewise very sensitive. Objec- 
tive evidences of inflammation are absent. This condition is 
considered as a simple "hyperesthesia of the endometrium." In 
many cases, however, there is probably an inflammatory inter- 
stitial or exudative condition in which other evidences of inflamma- 
tion are not present, and for that reason the cause in virgins is 
to be referred* back to the diseases of childhood. 

These are cases in which, according to Winter, a careful local 
examination shows no structural changes whatsoever, either in the 
uterus or in its lining. In these instances the dysmenorrhea is 
referred to excessive irritability of the genitalia and undue sensi- 
tiveness of the entire nervous system, so that the pre-menstrual 
congestion acts upon the uterus and all the other organs with 
unusual irritation. In the absence of inflammatory symptoms 



DYSMENORRHEA l6l 

dilatation of the cervix is a very good means for excluding the 
obstructive form of dysmenorrhea. 

Pre- menstrual symptoms result from the pre-menstrual 
congestion. There is a sensation of pressure or a feeling of swelling 
in the genito-urinary tract. The patients seem conscious of the 
presence of a sensitive uterus. There is a desire for frequent 
urination; there is a sensation of pressure in the rectum; there is 
pain in the back and in the legs. These symptoms are related to 
menstruation and its associated congestion. There are other 
symptoms of a general nature. 

Ovarian secretion causes a general pre-menstrual congestion 
involving the circulatory system, the nerve-centers, and the mucous 
membranes. The action of the ovarian secretion upon pulse 
tension, and its effect upon the mucous membranes of the body 
generally, are evidenced by the congestion of the vocal cords during 
menstruation, so that during this time the singing voice is poor. 
The secretion of intestinal mucus is also greater, there is increased 
perspiration, the lower turbinated bones are swollen, and the eye 
suffers limitations in power. 

The constitutional congestion of menstruation is apt to increase 
any annoyance existing in sensitive portions of the body. It 
increases the tendency to skin affections ; it increases the tendency 
to excitability, mild hysterical attacks, etc. These results are due 
to the perfectly physiologic constitutional congestion which occurs 
with and is associated with menstruation, but which acts with 
undue force on sensitive nervous systems. The patients are 
nervous or tired or excitable. They have a restlessness that is 
sometimes maniacal. There is palpitation of the heart; there is 
a change of temperament which is marked. They are mentally 
upset and sometimes melancholy. These symptoms are exaggera- 
tions of the complaints which even healthy women feel at this time. 
Such symptoms are not infrequently found with metritis and 
with inflammatory tubal and ovarian diseases. They are very 
frequent in women suffering from inflammatory endometritis, in 
whom, be it said, metritic, tubal, and ovarian changes often escape 
detection on bimanual examination. 

Schauta gives us the annoying symptoms noted in other organs 
than the uterus during menstruation, and especially in dysmenor- 



1 62 MEDICAL GYNECOLOGY 

rhea; feeling of heat, cold feet, frequent urination, dyspepsia, head- 
ache, hysteria, etc. As symptoms of the latter, there is anesthesia of 
the bulbi, hyperesthesia of certain points in the abdomen, singultus, 
spasm of the glottis, epileptiform attacks. Recurrences of dys- 
menorrheic pain are ofttimes enough to shatter the nervous 
system and to provoke neuroses and psychoses. One of the most 
important sequelae is headache, diffuse or of the form of hemi- 
crania. Long-existing dysmenorrhea increases the tendency to 
the development of hysterical attacks. 



TREATMENT OF DYSMENORRHEA 

The treatment of dysmenorrhea demands improvement of the 
general health. Especially is this true of the numerous cases due 
to uterine hypoplasia. (See Hygiene of Puberty.) 

In many of the latter it is not feasible to aid the development of 
the uterus by the use of the electric current or by the wearing of an 
intrauterine stem pessary. The negative intrauterine galvanic 
electrode is introduced into the uterus, or the faradic bipolar 
electrode is used in the uterus. Cases of hypoplasia should be 
treated by general tonics, by a generous diet, by plenty of outdoor 
exercise, and by hydrotherapy in the form of salt baths or Nauheim 
baths. The administration of iron and arsenic is advisable if 
there is any evidence of chlorosis. Drugs which have a more or 
less trophic action on the uterus, such as hydrastis and viburnum 
prunifolium, may be given for long periods; the fluidextract of 
hydrastis, 15 minims four times a day, and the fluidextract of 
viburnum prunifolium, 30 minims three times a day. Apiol, 4 
minims several times a day, in capsules, begun a week or ten days 
before each menstruation, or continued for weeks and months, is 
occasionally of aid. Ovarin (five grains three times a day) should 
be administered for several months. In some instances this 
administration of ovarin (gr. v in tablets t. i. d.) is of value, some 
of the subsequent menstrual periods taking place with much 
diminished pain, but rarely does this early improvement last for 
more than three or five months. The pain felt at menstruation 
then recurs with previous severity. Pain is diminished by rest 
in bed during menstruation. The bowels should be kept open 



DYSMENORRHEA 1 63 

and especially well before and during menstruation. The hot- 
water bag often gives great relief, and warm and even hot sitz- 
baths diminish the pelvic pain. A valuable combination consists 
of 10 minims of tincture of gelsemium, 10 minims of cannabis 
indica, in i dram of compound tincture of cardamon, given at 
least four times a day. 

1$. Tinct. gelsemii oiij 

Tinct. cannabis indie oiij 

Tinct. cardamon co q. s. ad oiij 

M. S. — 5 j t. i. d. and at night. 

Its administration should be begun several days before the outflow 
of blood and continued for several days. If this fails to stop the 
pain, the coal-tar products are of greatest value. Only the severest 
forms are to be relieved by hypodermic injections of antipyrin or 
of morphin. For quieting the associated nervous annoyances 
hyoscin hydrobromate, codein, and strontium bromid are of 
importance. 

The dysmenorrhea due to hypoplasia of the uterus is a dysmenor- 
rhea which often improves after marriage through the trophic 
effect of ovarian stimulation, and, of course, disappears after 
childbirth, if pregnancy takes place. 

The treatment of dysmenorrhea depends upon the cause. It 
goes without saying that the form dependent on obstruction 
to the outflow of blood in normally developed uteri, whether due, 
as it is in some cases, to a marked anteflexion of the uterus, or 
whether due, as it is in most of such cases, to overgrowth of endo- 
metrium in the neighborhood of the internal os, or to a narrow 
cervical canal, can be corrected only by removing the obstruction 
which is overcome naturally after childbirth. The diagnosis can 
be made by gently and carefully dilating the cervix a few days 
before menstruation. This can be done by the introduction of 
Weir's sounds of various sizes under strict aseptic precautions, or 
by introducing into the cervix cotton rolled on an applicator and 
dipped into lysol solution or sterilized vaselin. Each successive 
applicator is made larger, to that in the space of ten minutes the 
cervical canal can be dilated to a fair extent. A thin strip of 
iodoform gauze rolled into wick form is then introduced into the 
cervix and allowed to remain for twenty-four hours, being removed 



164 MEDICAL GYNECOLOGY 

by the physician at the next treatment. This procedure, carried 
out on two to four successive days before menstruation, relieves 
temporarily this form of dysmenorrhea and makes the diagnosis, 
if the cause is as above stated. Electricity is sometimes of benefit 
(p. 117). 

Such cases may be treated by the introduction of the stem 
pessary, to be worn more or less continually (Fig. 87). By some the 
wearing of the pessary during menstruation is advised; by others 
it is removed at this period. Although very good results have been 
reported, there is certainly this objection to the wearing of the 
stem pessary, that its presence constitutes an irritation which is 
likely to produce a more or less continued inflammation in the case 
of women subjected to the more or less continued introduction of 
bacteria through coitus. In cases of cervical catarrh and cervico- 
uterine infection the wearing of such a pessary is contraindicated. 

The operation of curetting and discission offers relief in some 
cases, not so much through the discission, which does not correct 
the obstruction existing at the internal os, but more so through the 
curetting, if this is carried out thoroughly. If the curetting is done 
so that the adenoid hypertrophy at the internal os is removed, 
relief is experienced, but very often only temporarily. 

A permanent cure of such cases can be absolutely accomplished 
by a high amputation of the cervix, the cervix being amputated 
at the level of the internal os. If, after operation, the internal os is 
kept open and dilated by iodoform gauze, or by a stem pessary 
introduced into the uterus until healing takes place without con- 
traction, the cure of the dysmenorrhea is absolute. This operation 
is contraindicated in hypoplasia. 

During dysmenorrhea relief may be obtained by rest in bed, by 
the application of hot-water bags, by warm saline enemata, and 
by the use of very hot vaginal douches. 

In those cases in which little blood is lost a course of carbonic 
acid gas baths is of value. If there is chronic congestion of the 
pelvis, prolonged cool sitz-baths, 50 to 65 , five to thirty minutes, 
are of importance during the intermenstrual period, and Glauber's 
salts should be taken. In nervous and hysterical women, with 
hyperesthesia of the endometrium, spastic contraction of the 
internal os takes place, and may result in the formation of small 



DYSMENORRHEA 1 65 

coagula in the uterine cavity. The uterus contracts to expel these 
clots, which process causes great pain. For treatment of the pain 
we make use of hot abdominal applications, warm or hot sitz- 
baths, full baths of a temperature up to ioo°, and warm vaginal 
douches. 

1$. Fl. ext. vib. opulus o j 

Elixir simplex o iij 

S. — oij in hot water every hour for six doses. 

1$. Strontii bromidi 5iv 

Elixir pepsin ohj 

S. — 5 j in water every three hours. 

In most cases of dysmenorrhea the coal-tar products must be 
given for the relief of pain, the best of these being triphenin, 7 
grains four times a day, or else antipyrin, combined with cafTein, 5 
grains three to four times a day. The former is not a cardiac depres- 
sant. Codein phosphate, J to J grain, added to the triphenin increases 
its value. Pyramidon, 5 grains, and aspirin, 5 grains, in combina- 
tion, four or five times a day, with or without codein, are helpful. 
Apiol, 5 to 10 grains, in capsules, has worked well in the hands of 
many, often combined with ergot. Dionin (J to J grain) in tab- 
lets or in solution, several times daily, is an antispasmodic and anal- 
gesic worthy of trial. 

I}. Triphenin gr. v 

Ft. tal. caps. no. xx. 

S. — One every two hours for five doses. 

1$. Aspirin gr. iij 

Pyramidon gr. iij 

Ft. tal. caps. no. xx. 

S. — One every three hours. 

1^. Triphenin gr. iiss 

Antipyrin gr. iss 

Codein phosph gr. % 

Ft. tal. caps. no. xx. 

S. — One every hour for three doses. Then every three hours. 

In extremely severe cases of dysmenorrhea, especially of ovarian 
dysmenorrhea, antipyrin in hypodermic solution (5 grains) is 
often of remarkable efficiency, and takes the place of morphin, 
the use of which sometimes cannot otherwise be avoided. A drug 
which is of some relief in all forms of dysmenorrhea, especially 
in the form existing without any diagnosed alteration except 
uterine hypersensitiveness to the sound, or associated with general 
nervous phenomena, is bromid in the form of bromid of strontium, 



1 66 MEDICAL GYNECOLOGY 

10 grains to the dram of water every three hours. In some cases 
chloral hydrate, 3 grains, and the fluidextract of viburnum opulus, 
1 5 minims in a dram of simple elixir, taken every hour in hot water 
for several hours, relieves the pain. 

1$. Strontii bromidi 5iv 

Elixir pepsini §iij 

Dram 1 in water every three hours. 

1$. Fl. ext. choral hydrate 5 iss 

Ext. vib. opulus 5 j 

Elixir simplex ad §iv 

S. — One teaspoonful in hot water every hour for 6 doses. 

In those cases in which the dysmenorrhea is associated with the 
expulsion of much blood in the form of smaller or larger clots, 
stypticin, 2 grains, several times a day, should be given. When 
associated with an enlarged uterus of the form of fibrosis, ergotin 
(Bonjean), 2 grains four or five times a day, should be added. 
Curetting, however, is often an essential procedure for such cases. 

1$. Triphenin gr. iij 

Stypticin gr. iss 

Ft. tal. caps. no. xx. 

S. — One every two hours. 

I}. Triphenin gr. iij 

Stypticin gr. iss 

Ergotin gr. iss 

Ft. tal. caps. no. xx. 

S. — One every two hours. 

In the intrauterine treatment of some cases excellent results 
have been reported from the use of electricity, the positive pole 
(by some the negative) being applied in the uterus. This good re- 
sult is not very promising in the dysmenorrhea due to hypoplasia. 
In some cases, naturally only those of the most severe and abso- 
lutely unbearable type, when all other means have been exhausted 
the removal of the ovaries furnishes the only possible relief. 

In the treatment of acquired uterine dysmenorrhea we are con- 
cerned with the care of alterations resulting, in almost all cases, 
form inflammation; we are concerned, therefore, with the intermen- 
strual treatment of the cause, wherever localized, and with the treat- 
ment of the pain occurring at menstruation. The treatment of the 
pain demands those drugs, such as the coal-tar products, codein, 
pyramidon, and dionin, which diminish pain. The intermenstrual 
treatment demands attention to the cervical catarrh, to the involve- 



DYSMENORRHEA 167 

ment of the endometrium sometimes associated with hyperplasia, 
to the inflammatory metritis, and to the tubal, ovarian, and perito- 
neal complications ( intra vaginal pressure therapy, douches, 
sitz-baths, Xauheim baths, etc.). 

The treatment of the pain occurring before and during menstrua- 
tion in ovarian dysmenorrhea is by the coal-tar products, bromids, 
and codein. This pain, so often accompanied by nausea, is often 
not relieved by such medication. In fact, this failure is important 
in aiding the diagnosis of structural ovarian involvement. Ovarian 
dysmenorrhea is so very often considered a manifestation of neuras- 
thenia and hysteria that a great injustice is done to many such 
long-suffering patients. Even if macroscopic and microscopic 
changes are slight, that does not alter the fact that it is the ovulation 
and menstrual congestion in the ovary which produce the steady, 
constant pain. If the pain is great enough and of sufficient 
duration to undermine the patient's nervous system, and if general 
and local treatment fails to improve the local annoyance, removal 
of the involved ovary is essential to prevent many such cases 
from becoming nervous wrecks. In most of these cases a varicose 
condition of the broad ligament is present. The ovary, tube, and 
upper half of the broad ligament and the ligamentum infundibulo- 
pelvicum must be removed. If the right ovary is the one involved, 
the appendix should certainly be removed. In those cases in 
which large amounts of blood are lost, and in which pain is increased 
by the expulsion of clots, treatment directed to the diminution of 
the amount of blood lost is an essential factor. 

The treatment of dysmenorrhcea membranacea is thorough 



UTERINE BLEEDINGS 

Causes. — Carcinoma or sarcoma of the vagina is productive of 
bleedings on vaginal manipulation. Carcinoma of the vagina 
generally takes the form of flat infiltrations which affect* part or 
all of the vaginal wall. Occasionally vaginal carcinoma takes 
the form of large tumors of broad extent filling the lumen of the 
vagina, or of papillary bleeding projections lying on the surface 
and affecting the whole vagina without deep infiltration. The 
infiltrating form may extend under the mucosa and gradually 
involve the whole length of the canal, making it scarcely passable 
for one finger. Sarcoma of the vagina causes flat ulcerating 
infiltrations or rounded tumors covered by mucosa. Sometimes 
there are grape-like bodies, also found in children. Otherwise 
it is not to be diagnosed clinically from carcinoma. When ulcera- 
tive changes result in arrosion of capillaries and vessels, the bleed- 
ing is profuse. 

Erosions of the cervix are productive of but the slightest bleed- 
ings. Marked hemorrhage from the cervix may come with carci- 
noma, sarcoma, or myoma of the cervix, and especially from 
small cervical polyps. 

Bleeding from the uterus may depend on general or local states. 
There are general blood-states in which blood coagulation takes 
place slowly, which may lead to loss of much blood from the uterus 
(scurvy, leukemia, anemia, hemophilia). 

Perhaps some instances of bleeding are due to increased vascular 
tension. Passive congestion from a disease of the heart, lungs, 
and liver, etc., is supposedly a cause of profuse uterine bleeding. 
It may be stated, however, that diseases of the heart are more 
frequently followed by a diminished flow of blood. 

Congestion in the uterine tract resulting in bleeding may be pro- 
duced by retroflexions of the uterus. Retroflexions are a possible 
cause, especially such as occur after abortion or after labor, and 
which prevent the involution of that organ. Koblanck observed 

1 68 



UTERINE BLEEDINGS 1 69 

that menorrhagia was often due to masturbation and to disturb- 
ances of a sexual character. Sixteen women with menorrhagia 
and metrorrhagia acknowledged abnormal sexual practices, espe- 
cially coitus interruptus, due to a desire to avoid conception. The 
symptoms improved with the regulation of the sexual relation. 
Inflammatory involvement of the peritoneum causes congestion 
in the uterus. 

In addition to such causes hemorrhage from the uterus is due to 
some involvement of the uterine lining, with or without an enlarge- 
ment of the uterus, to some structural, involvement of the wall, 
with or without enlargement of the uterus, or to new-growths in the 
uterus or its cavity, which are, as a rule, associated with enlarge- 
ment of the uterus. 

Definition. — Excessive or prolonged bleedings from the uterus, 
which follow more or less the regular four- weekly rhythm of men- 
struation, and which are associated with the local and constitutional 
symptoms of menstruation, are called menorrhagia, whereas bleed- 
ings which are of an irregular, intermenstrual character are called 
metrorrhagia. The two often so run into each other that the 
bleeding cannot be called either menstrual or intermenstrual, but 
is called an irregular bleeding (Winter). 

In the discussion of those cases where regular profuse bleedings 
have occurred for some time, the element of existing pregnancy, 
impending abortion, ectopic gestation, and placenta praevia can, as 
a rule, be excluded. 

We are dealing in menorrhagia with excessive menstrual bleed- 
ings, which, according to Winter, imply conditions which increase 
and lengthen the four-weekly congestive hyperemia, or conditions 
which do not cut the hyperemia short. Inflammatory conditions 
about the uterus, fibroids, " endometritis," atrophy or atony of the 
uterine wall, subinvolution fibrosis, and metritis are to be considered. 

Periuterine Inflammation.— Inflammatory involvement of the 
ovaries is productive of irregular bleedings. Acute pyosalpinx 
in its earlier stages also causes hemorrhage from the uterus. The 
existence of parametritis or a stump exudate causes congestion 
in the uterine structures and irregular hemorrhages. Sometimes 
acute or chronic pelvic inflammation or pelvic exudates are pro- 
ductive of regular bleeding because, in addition to an acute or 



170 MEDICAL GYNECOLOGY 

chronic inflammation of the uterine lining and its wall, there is 
congestion and exudation about the uterus. 

Inflammation of Endometrium. — Involvement of the endo- 
metrium associated with bleedings may be also the sequela of infec- 
tious diseases, such as typhoid, pneumonia, influenza, scarlatina, 
etc., which produce structural changes and hemorrhagic endome- 
tritis. Chronic endometrial hyperemia is often increased by 
inflammatory conditions about the uterus. With any inflammation 
of the endometrium the interstitial tissue is infiltrated with small 
cells in proportion to the severity of the inflammation. The 
round cells completely replace the original cells of the interstitial 
tissue in certain areas, so that gland sections are absolutely sur- 
rounded by small-celled infiltration. The epithelial cells of the 
glands proliferate in certain areas as a result of the increased blood- 
supply. The small round cells become larger and epithelioid in 
form through the increased nutrition due to the newly formed 
vessels present with inflammation. In the early stages, the entire 
mucous membrane is thickened, there is marked hyperemia, and 
the endometrium looks extremely red. 

Overgrown Endometrium. — An overgrown hyperplastic endo- 
metrium, whether the result of such inflammation or of subinvolu- 
tion after labor or abortion, or of retention of decidua, of the form 
of the so-called fungoid, hyperplastic "endometritis," is very 
frequently productive of regular uterine bleeding. The vessels may 
show no change, they may be dilated, there may be hemorrhage 
in the tissue, the walls of the capillaries may be thickened, the 
entire endometrium may evidence so much blood as to deserve 
the name of apoplexy. The vessels and capillaries of the endome- 
trium may be brittle and show changes of an arteriosclerotic 
nature, so that menstrual bleeding is controlled with difficulty. 
With these changes of the endometrium the uterine wall is often 
altered, but not always enlarged. 

Changes in the Uterine Wall. — A point of importance is the 
necessity of considering the affections of the endometrium in 
conjunction with changes in the structure of the uterine wall. 
If we are dealing with an endometritis inflammatory in its charac- 
ter, we must consider that the same bacteria or cocci may, and 
probably do, involve the uterine wall, producing changes there 



UTERINE BLEEDINGS i;i 

in the character, amount, and structure of the component elements, 
and that this alteration in the function of the uterine wall has a 
bearing on the symptoms supposedly or actually associated with 
the involvement of the endometrium alone. On the other hand, 
changes in the ovaries (trophic centers) or such changes as are asso- 
ciated with pregnancy in the tube or uterus, may likewise produce 
alterations in the uterine wall. The important changes in the 
uterine wall from a non- inflammatory cause are those changes 
known as subinvolution, which means hypertrophic and fibrotic 
alteration in the uterine wall with consequent modification of the 
symptoms supposedly or actually associated with alterations of 
the uterine lining. 

There are alterations in the structure of the uterine wall, with 
or without enlargement of the uterus, which are of a nature like 
those affecting the muscle of the heart. There may be atony or 
atrophy of the muscle fibers. The uterine wall is structurally 
changed by numerous labors and abortions. The elasticity of the 
muscle fibers is diminished, their place is taken by fibrous connec- 
tive tissue, there is a new-growth of connective tissue, or newly 
grown elastic fibers of poor contractile force have appeared. The 
uterine wall may be infiltrated as a result of acute or chronic inflam- 
matory involvement and there are muscle fibers of poor contractile 
power or newly formed infiltrating tissue, with consequent inability 
on the part of the uterus to contract and to close the vessels. As 
the consequence of numerous labors and abortions, there is found, 
especially about the climacteric age, an involvement of the vessels 
characterized by changes in the intima and adventitia which makes 
them brittle. Such an arteriosclerosis with lack of elasticity 
and lack of contractility renders capillary and arterial hemorrhage 
easy. 

Uterus Not Enlarged. — A change in the uterine lining produc- 
tive of hemorrhage, with a uterus not enlarged, is the result of a 
hyperplastic endometrium or of an endometritis both glandular 
and interstitial, or of a beginning carcinoma. The use of a sound 
may exclude these conditions if the endometrium feels smooth. 
A test curettage must be done if carcinoma is suspected. The 
clinical history is of greater importance than the finding obtained 
by the use of the sound. If the endometrium is not involved, the 



172 MEDICAL GYNECOLOGY 

uterine wall may be the responsible factor, through atrophy or atony 
of the muscle fibers or through sclerosis of the blood-vessels. 

In women who have never been pregnant menorrhagia may be 
due to uterine congestion. In some cases retroflexion may be 
responsible for menorrhagia. Fibroids when small cause menor- 
rhagia, and even when large only cause menorrhagia if they are 
interstitial or subserous. "Endometritis" hyperplastica is also a 
cause. A not infrequent cause in women who have not been preg- 
nant is tubo-ovarian inflammation. In some cases a polyp may 
be the cause of menorrhagia. These conditions of uterine conges- 
tion and displacement, endometritis, inflammation of the adnexa r 
and polyps all produce exaggerated four-weekly congestion. 

Menorrhagia which occurs with retroflexion generally means 
a congestion associated with subinvolution or with fibrosis, or 
it may mean "endometritis" hyperplastica, or both. When regular 
profuse bleedings are associated with a chronic catarrh, inflamma- 
tory endometritis or metritis is probable. If there is no catarrh, 
and if there are no evidences of inflammation, the condition is 
either hyperplastic endometrium or a structural change in the uterine 
wall. The use of the sound, the size of the uterus, and the amount 
of material obtained by a curettage give proof as to which factor is 
important. 

Enlarged Uterus. — With regular increased bleeding from an 
enlarged uterus it is important to exclude the retention of fetal or 
decidual structures and the rare occurrence of menstrual bleeding 
in pregnancy. The other forms of regular bleeding from an 
enlarged uterus indicate involvements of the wall due to chronic 
metritis or subinvolution, or to myoma or large polyps. Though 
sarcoma and carcinoma generally cause irregular bleedings, the 
diagnosis should not be made by this irregularity alone. 

The subinvolution occurring after labor or abortion, with or 
without associated inflammation, if not corrected, results in 
chronic hyperemia, in a large cavity which offers no obstacle to the 
periodic swelling of the endometrium, and in a muscle wall of 
diminished contractile power. As a consequence the flow of blood 
is not cut short and excessive menstruation occurs. Associated 
with this condition may be dysmenorrhea, which is due either to 
expulsion of large clots by increased contractions, or else it may be 



UTERINE BLEEDINGS 1 73 

due to inflammatory changes. More frequent than simple sub- 
involution after a labor or abortion is chronic subinvolution com- 
plicated by fibrosis, a change which implies the formation of new 
connective tissue in a uterus which has gone through pregnancy 
or abortion without complete involution. Here, too, there is a 
large uterine cavity, there is no resistance to the swelling of the 
mucosa, the vessels are not compressed by the uterine wall, there 
is atony of the uterine wall, there is arteriosclerosis. 

Fibroids. — The symptoms which fibromyomata produce are 
increase in size of the uterus, generally with enlargement of the 
uterine cavity; bleeding, especially in the submucous and some- 
times in the interstitial variety. (They rarely produce pain, unless 
incarcerated beneath the promontory of the sacrum, or unless the 
blood which is poured out coagulates quickly and is expelled from 
the uterus as large clots.) Fibromata in their growth are sur- 
rounded by a zone rich in blood-vessels, for in the fibroid itself 
the blood-supply is poor. Either this zone comes close to the 
surface of the uterine, lining or else the mucosa over the fibroid 
is in a state of hyperplastic development, or else it is thinned out, 
or else the surface of the fibroid projects, in broad-based or poly- 
poid form, into the cavity of the uterus. Under such circumstances 
bleeding, which is generally of the form of menorrhagia, may 
sometimes take the form of metrorrhagia. Hemorrhage is most 
marked in the submucous or polypoid form. In fibroids situated 
interstitially, and especially subperitoneally, irregular bleeding 
is rarely a symptom. They evidence themselves then mainly 
through the increased size of the uterus and through pressure- 
effects on the surrounding structures, such as intestine or rectum, 
bladder or ureters. 

In addition to hemorrhage, which may be of the form of either 
menorrhagia or metrorrhagia, there may be pain through weight 
and pressure of the fibroid, there may be dysmenorrhea due to 
the expulsion of large clots through the cervix, or there are evidences 
of pressure on the bladder, ureters, rectum, or sacral nerves. 
Incarceration within the pelvis of uterine and especially of cervical 
fibroids may compress the bladder, causing great distention of 
that organ with pain and constant dribbling of urine. 

An interstitial myoma or fibroma being situated in the wall of 



174 MEDICAL GYNECOLOGY 

the uterus is covered with muscle fibers. The diagnosis from, 
chronic metritis or fibrosis is difficult if the uterus is small. In 
chronic metritis the uterus is evenly enlarged, the corpus and fun- 
dus are both thickened. If a sound is passed into the uterus and the 
uterus is palpated through the abdomen, by manipulation of the 
sound the even or uneven thickening of the uterine wall may be 
noted. The larger the uterus and the harder the uterus, the more 
probable is the existence of fibromyoma. The uterus is then 
enlarged, the cavity is lengthened and widened. An interstitial 
myoma of the cervix gives an irregular knotty wall. With an 
even enlargement of the uterus by a fibroid the diagnosis from 
pregnancy in the early months is often difficult, especially from 
pregnancy with dead fetus. With a living fetus the most important 
sign is the change of consistence which the uterus undergoes in 
the course of a few minutes under bimanual examination. The 
myomatous uterus is usually harder. In the later months the 
symptoms of pregnancy and the evidences of fetal movements 
and the beating of the fetal heart make the diagnosis. 

A not infrequent differential diagnosis is to be made from re- 
trouterine hematocele. The latter, however, becomes harder 
and harder after the blood has coagulated and causes peripheral 
adhesions and is more closely connected with the pelvic wall. 
In differentiating an intraligamentous fibroid from intraligamen- 
tous hematoma it is to be noted that the latter shrinks gradually. 
With myoma the uterus is enlarged, but in many cases the differen- 
tial diagnosis is difficult and can only be made after continued 
observation. A retrouterine fibroid must be distinguished from 
the retroflexed fundus by rectal examination and by the use of the 
sound. 

Submucous fibroids, whether broad-based or pedicled, grow 
toward the uterine cavity and are covered with mucosa. If such 
a fibroid grows into the uterine cavity, it dilates the uterus and the 
cavity is lengthened and widened. It stimulates the uterus to con- 
traction, which may cause the fibroid to protrude from the cervix 
as a fibrous polyp. The submucous type causes much bleeding. 
The uterus is enlarged and round, the portio is felt to pass over 
into the enlarged uterus. A submucous fibroid often dilates the 
cervix and the lower uterine segment like a balloon. A differen- 



UTERINE BLEEDINGS 175 

tial diagnosis must be made from pregnancy and from metritis. 
The cervix is dilated during menstruation, and if the finger is then 
passed into the cervix, a foreign body is felt in the case of a sub- 
mucous fibroid. This must be differentiated from an ovum or 
the retained products of an abortion. It must be remembered 
that an ovum or any of its retained parts may be loosened from the 
wall of the uterus by the examining finger, whereas a fibroid can- 
not. A retained placenta may be so firmly adherent as to be diag- 
nosed as fibroid. Mucous polyps are to be diagnosed by the 
fact that they are oval, lobulated and soft, and have a thin pedicle. 

Metrorrhagia. — Metrorrhagia is a bleeding of different type. 
There is either too short an interval or else the bleeding lasts very long. 
It is due to abortion, ectopic gestation, fibrosis uteri, arterio- 
sclerosis, fibromyoma, polyps, sarcoma, or advanced carcinoma. 

Important causes of metrorrhagia are new-growths, (i) asso- 
ciated with pregnancy, an ovum in the uterus or in the tube, or 
placenta praevia or chorioepithelioma, or (2) tumors not asso- 
ciated with pregnancy, such as polyps, fibroids, sarcoma, carci- 
noma. When fibroids become larger, and especially if they are 
submucous or polypoid, the bleeding may become intermenstrual. 
Therefore continued metrorrhagia is generally due to actual 
diseases of the uterus itself. As Winter says, intermenstrual 
bleeding speaks for permanent structural changes. Therefore 
in numerous cases we are dealing with new-growths, or with polyps, 
in instances of long-existing bleedings. When an intermenstrual 
bleeding first takes place and is seen for the first time, abortion 
and ectopic gestation should first be considered. 

New-growths, Including the Ovum. — Many cases of metror- 
rhagia from an enlarged uterus, aside from those instances due to 
metritis or subinvolution fibrosis, are due to the presence of foreign 
growths. A carcinoma in the early stages by no means implies an 
enlarged uterus. 77 produces only an oozing and a discharge of 
sero- sanguineous fluid, but in the later stages arrosion of blood-ves- 
sels may be associated with profuse hemorrhage. The same holds 
good for sarcoma, and especially for chorioepithelioma, in which 
the tendency to the erosion of blood-vessels is extremely marked. 
Fibroids which have about them a zone of tissue rich in blood may 
be productive of great bleeding, especially if this area is situated 



176 MEDICAL GYNECOLOGY 

close under the mucosa or if the fibroid thins the mucosa over it. 
In addition, the presence of a fibroid prevents the uterus from 
contracting and limiting the hemorrhage. Polyps may cause 
profuse bleeding from open vessels. So rich is the blood-supply 
of a polyp that the bleeding may be most profuse. A uterus en- 
larged by the presence of an ovum which is being expelled or which 
is retained in whole or in part, or in which a low embedding has 
resulted in placenta praevia, is a very frequent cause of bleeding. 
So long as the ovum, or part of it, is still attached, vessels or capil- 
laries are open, thrombi do not form, the uterus cannot contract, 
the bleeding continues. A tubal gestation is almost invariably 
interrupted by bleeding in the tube, by tubal abortion, or by tubal 
rupture. This interference with the life of the ovum causes the 
expulsion from the uterus of the decidua by uterine contractions. 
Hence oozing, irregular bleeding, and in the later stages the 
expulsion of decidua occur. 

Single Strong Bleedings. — A single strong bleeding occurring 
for the first time must always be viewed as a possible abortion or 
as an ectopic gestation, and these conditions must be differentiated 
or excluded by examination. Such a single strong bleeding, 
according to Winter, not infrequently takes place as the first 
menstruation after labor, or the first menstruation after a long 
period of amenorrhea. Here the history and size of the uterus 
are of importance. Examination in such cases by a sound shows 
the uterus to be clean. In this first bleeding occurring after a 
completed labor or abortion, the large cavity of the uterus offers 
no obstacle to the swelling of the mucosa, the uterus has not 
regained its contractile power, and prolonged hemorrhage may 
take place. The other conditions related to pregnancy which must 
first be excluded are abortion, ectopic gestation, and placenta 
praevia. 

Ectopic Gestation. — Most cases of ectopic gestation present 
a group of symptoms preceding the tragic stage of diseases suffi- 
ciently distinctive to warrant a diagnosis, and since these symp- 
toms are in no way alarming, they are called the non- tragic symp- 
toms of ectopic gestation. The two symptoms of greatest value 
are: (a) atypical menstruation or metrorrhagia, (b) pains. 

Atypical menstruation of ectopic gestation means the appearance 



UTERINE BLEEDINGS I 77 

of blood generally out of rhythm with the normal menstrual cycle 
of the individual. The amount of blood lost may be very much 
greater, or very much less, than the usual menstrual flow of the 
patient. It may be continuous or appear with interruptions. It 
may be darker or may be lighter or more brownish than the usual 
menstruation. The metrorrhagic blood of ectopic gestation very 
often has a slippery character almost sufficient at times to diag- 
nosticate ectopic gestation by the effect of such discharge upon the 
tactile sense. 

The colicky sharp pains of ectopic gestation are generally closely 
attended by the appearance of a bloody discharge from the vagina. 
If the patient is intelligent, she will at once know wherein the pains 
and the flow of the present attack differ from her previous and 
painful menstruations. If the colics are very severe, with steady 
pains between them, the abdominal walls may be rigid. The 
colics in the beginning of tubal pregnancy are often mistaken for 
intestinal pains. They may not cause the patient to rest more 
than momentarily from her work or pleasure. Except for brief 
intervals of an hour, or a few hours or so, a large proportion of 
the cases of ectopic gestation pursue their usual vocations during 
the non-tragic stage without material or prolonged interruptions 
(Harris) . 

Morning sickness and enlargement of the breasts, which are the 
ordinary symptoms of intrauterine pregnancy, do not belong to the 
symptomatology of extrauterine pregnancy. Miscarriage is often 
diagnosed by the patient or another physician. If the patient is 
still bleeding and has pains, we should be slow to accept such 
statement, unless a fetus has actually been seen by some one. 
Twenty per cent, of the cases of ectopic gestation are subjected 
to the operation of curettment for the cure of metrorrhagia, the 
real cause of the metrorrhagia not having been suspected (Harris). 

In the non-tragic stage the pregnant tube is usually sufficiently 
large to be palpated, and possibly also approximately measured by 
bimanual palpation. A pregnant tube is always tender when 
squeezed, and may be extremely painful when so treated. The 
tube may be embedded in blood-clots, or so displaced or partly 
or completely engulfed in blood as not to be made out. 

When any woman after puberty and before menopause who has 



178 MEDICAL GYNECOLOGY 

menstruated regularly and painlessly goes jour, five, six, eight, 
ten, fifteen, eighteen days over the time at which menstruation 
is due, sees blood from the vagina differing in quality, color, quantity 
or continuance from her usual menstrual flow, and has pains, 
generally severe, in one side of the pelvis or the other, or possibly 
in the hypogastric region, ectopic gestation may be presumed (Harris). 

Uterine Abortion. — The symptoms of abortion are bleeding, 
pain caused by uterine contractions and by dilatation of the cervix, 
and local cervical evidences of an attempt at expulsion of the 
uterine contents. The bleeding is either the primary or the sec- 
ondary factor. It is primary if a hemorrhage takes place which 
acts as a mechanical factor in separating the ovum. It is secondary 
if the ovum dies or is partly separated and, being then a foreign 
body, the uterus contracts in its attempt to expel it. Uterine con- 
tractions continue to separate the ovum, more bleeding takes place 
between ovum and decidua serotina, and blood is poured out of the 
cervix. The pain associated with abortion is due to uterine con- 
tractions and to cervical dilatation, and for exactly the same reasons 
as at full term. The uterus contracts close down upon the egg, 
blood accumulates in the uterus, the uterus contracts to expel the 
blood, and this process may loosen the unruptured ovum entirely 
from contact with the uterine wall. Not only the uterine 
contractions but also dilatation of the cervix produces the pain. 
The degree of dilatation of the cervix, then, is one of the means of 
determining whether abortion is progressing or not. Given a 
uterus which is bleeding, in which pain is slight, in which the 
cervix is not dilated, and we are here concerned with a case in which 
the bleeding and the progress of the abortion may under proper 
treatment cease. If, however, bleeding continues, it threatens 
the life of the ovum. If the blood which is poured out accumulates 
in the uterus in the form of clots, it stimulates the uterus to further 
contractions. If the ovum is partially separated from the uterine 
wall, or if the embryo is dead, the uterus naturally reacts by further 
contractions. Therefore, the continuation of uterine pain and the 
increasing dilatation of the cervix are indices of an inevitable abor- 
tion. 

An inevitable abortion is associated with the loss of much blood 
and of fresh blood, whereas irregular bleeding or the loss of brown- 



UTERINE BLEEDINGS 1 79 

ish blood mixed with mucus does not indicate immediate danger. 
When, in addition to the loss of fresh blood, pains come on, this 
combination has a more direct meaning. If at the same time the 
uterus becomes more tense or becomes harder, it indicates that 
abortion is in progress. If, then, the cervix is open and the internal 
os admits one finger, we are concerned with dilatation of the cervix, 
which is a most important sign of inevitable abortion. 

Hegar's sign is important in those early cases seen for the first 
time, and in whom pregnancy has not been previously diagnosed; 
especially so if there is a history of long-continued irregular men- 
strual periods and if ectopic gestation is suspected. An important 
aid is the introduction of the finger into the uterus when the cervix 
is open. In beginning abortion the finger feels the round ovum 
more or less cystic. In incomplete abortion the finger feels re- 
tained villi or decidua or retained placenta, which are recognized 
by the fact that they can be peeled off with the fingers. Sometimes 
such structures are seen projecting from the cervix. 

Menstrual bleeding in the course of uterine pregnancy may be 
due to a double uterus, to endometritis, to the coexistence of a 
fibroid, polyp, or carcinoma. Spotting or bleeding in the early 
weeks or months of a pregnancy means endometritis deciduae or 
ectopic gestation. 

Chorioepithelioma. — Chorioepithelioma occurs from six weeks 
to three years after labor or an abortion. (It never occurs in a 
nullipara.) In 50 per cent, of the cases it follows the occurrence 
of hydatid mole. 

The clinical symptoms are: (1) Pronounced uterine hemor- 
rhage recurring even after repeated curettings; (2) very early 
metastases, especially in the lungs and vagina; and (3) early 
death through hemorrhage, cachexia, or septic infection. Macro- 
scopically, these tumors are more or less localized, ulcerating, degen- 
erating, hemorrhagic growths, frequently passing deeply into the 
uterine wall, or through it, with involvement of the peritoneum. 
Microscopically, these tumors are characterized by hemorrhagic 
areas, areas of degeneration, the presence of fibrin, and the involve- 
ment and invasion of capillaries and large vessels. The diagnosis 
is verified by the microscope. (See section on Chorioepithe- 
lioma.) 



l8o MEDICAL GYNECOLOGY 

Arteriosclerosis and Fibrosis Uteri.— When menstruation 
becomes severe, menorrhagia or metrorrhagia occurs, and no local 
changes in the endometrium can be observed with a sound or with 
the examining ringer, we may take it for granted that one or all 
of the following conditions are present: (i) Degenerating muscle 
fibers poor in contractile power; (2) an increased amount of fibrous 
connective tissue; (3) an increased amount of elastic fibers, thick- 
ened and brittle; (4) arteriosclerotic vessels. • Age is no criterion, 
since these changes may occur long before the natural climacteric 
period. If ergotin, stypticin, etc., are of no avail; if no decided 
changes in the adnexa sufficient to warrant their being considered 
the causal factors are found, and if curetting shows no altered 
condition of the endometrium; and if, above all, a curetting does 
not control the hemorrhage, then the diagnosis of muscular degen- 
eration, fibrosis uteri, or arteriosclerosis must be made. 



DIAGNOSIS OF THE CAUSE OF METRORRHAGIA 

In making the diagnosis it is important to consider the various 
aids. The sound tells us the size of the uterine cavity, the smooth- 
ness of the lining, the presence of foreign bodies, or the sensitive- 
ness of the lining. 

Pain is associated with abortion, ectopic gestation, with the 
expulsion of clots, or with an inflammation. Purulent' and muco- 
purulent discharge from the uterus or cervix speaks for an inflam- 
matory condition. We should consider the meaning of a previous 
amenorrhea. We should question as to the influence of cohabita- 
tion, which in carcinoma produces an oozing. We should take 
into consideration the history of previous abortions and labors 
and should take cognizance of the age of the patient, and most 
especially the history of bleeding following a period of amenorrhea 
at the climacteric age. The character of the blood is of im- 
portance. A fresh gushing hemorrhage speaks for an open vessel, 
and is found in abortion, malignant degeneration, and with polyps. 
The presence of pieces of blood or coagula implies a bleeding so 
rapid that the uterine secretion cannot prevent the clotting. It 
is observed in fibroids, with carcinoma, with polyps, and with 



UTERINE BLEEDINGS l8l 

abortion. A dirty, brown-red discharge means long retention in 
the uterus, and is frequently seen in conditions related to pregnancy. 
A syrupy, thick discharge means hematocolpos. 

When irregular bleedings occur in a patient without leukorrhea 
in whom there is no evident cause for hemorrhage, and if the endo- 
metrium is normal, the adnexa are not inflamed, and if there is a 
history of frequent labors, especially so if the patient is about the 
menopause age, metritis, fibrosis uteri, or arteriosclerosis are the 
responsible factors. 

Those causes which before the climacterium cause hemorrhage 
through hyperemia of the mucous membrane (interstitial endome- 
tritis, myoma, periuterine inflammation, and circulatory disturb- 
ances) are of little moment after menopause. The bleedings 
which occur in this post-climacteric stage may be due to ulceration, 
erosions, colpitis senilis, mucous polyps, submucous myomata, etc., 
but 65 per cent, of the cases of bleedings in the post-climacteric 
period are due to carcinoma. 

In the early stages of carcinoma the diagnosis can often be made 
only by microscopic examination. A test excision or test curettage 
should be made in every doubtful case, since the clinical symptoms 
alone are such as to suggest a probable diagnosis of " chronic 
metritis," "endometritis," "erosion of the cervix," "ulcers," etc. 
"Chronic endometritis with long-continued profuse menstruation" 
is a frequent diagnosis when there is really carcinoma of the fundus 
either circumscribed, diffuse, or polypoid in form. Corpus 
carcinoma is characterized by its slow, localized development, 
and may be for months or even years confined to the uterus itself, 
with very slow or late extension into the broad ligament. 



TREATMENT 

The treatment of carcinoma and sarcoma of the vagina is surgical 
in those cases seen sufficiently early to permit the removal of the 
entire vaginal wall together with the uterus and the adnexa. In 
more advanced cases nothing can be done except to carefully curet 
ulcerating degenerating areas, to cauterize them with the actual 
cautery, and to keep them as clean and dry as possible. 

The treatment of uterine carcinoma is operative, in cases with 



1 82 MEDICAL GYNECOLOGY 

none or very little extension into the parametium. Palliative 
treatment in non-operative cases means curetting away of the 
carcinomatous tissues of the cervix, followed by the application 
of the actual cautery, followed by a packing of the resulting cavity 
with cotton covered with equal parts of iodoform and tannic acid. 
Care should be taken to avoid, during the curetting, perforation of 
the bladder, rectum, or ureter. 

The treatment of chorio epithelioma is surgical. 

The treatment of polyps, whether of the cervix or uterus, 
means their actual removal. Polyps of the cervix may be removed, 
under strict aseptic precautions, by the cutting of the pedicle, 
followed by the application to the stump of carbolic acid or nitric 
acid or the actual cautery. Polyps of the uterus, if small, should 
be curetted away. If large and situated near the fundus, or if 
of broad base, their removal implies a delicate surgical operation, 
not infrequently combined with a long incision of the anterior 
wall of the cervix and uterus to permit of direct approach to the 
polyp. 

The treatment of abortion is given on page 190. 

The treatment of ectopic gestation is entirely surgical. 

In any of the bleedings associated with the acute infectious 
diseases the vagina should be douched daily with a 1 per cent, 
carbolic acid solution, and subsequent observation should be 
directed to the prevention of atresia. 

In senile vaginitis the mucous membrane is often very thin, 
extremely red and congested, and often eroded. The slightest 
force on examination, or the use of specula, cause bleeding. Senile 
vaginitis should be treated by regular vaginal bathings with pure 
pyroligneous acid three times a week, carried out through the 
Ferguson speculum, combined with daily douches consisting of a 
tablespoon of pyroligneous acid to each quart of water. 

Erosions are sometimes so sensitive and contain so many capil- 
laries that any but the most gentle touch will cause oozing and 
bleeding. Erosions are best treated by the local application of 
pure carbolic acid, followed by a thorough painting with tincture 
of iodin, followed by boroglycerin poured into the vault of the 
vagina, after which the vagina is packed with gauze. In the later 
stages solutions of nitrate cf silver stimulate the healing process. 



UTERINE BLEEDINGS 1 83 

The following drugs are used in the treatment of uterine bleed- 
ings. 

Ergot has the effect of contracting blood-vessels and has an 
especial power in producing contraction of the uterine muscle. 
It is decidedly valuable when the uterus is atonic or dilated as a 
sequence of pregnancy or abortion. It naturally has a much 
diminished influence when the muscular elements of the uterus are 
degenerated or replaced by fibrous connective tissue. Ergot con- 
tracts the uterine muscle and raises the blood-pressure. It finds 
its most frequent application in overcoming or avoiding post- 
partum hemorrhage, in aiding the emptying of the uterus in abor- 
tion, and in aiding involution of the uterus. It should be used 
sparingly in the first week after labor, as it has a tendency to dimin- 
ish or stop the secretory function of the breasts. Ergot requires 
from fifteen to twenty minutes to produce a result when given by 
the mouth. Ergotol is two and one-half times as strong as the 
fluidextract of ergot and it works especially well and rapidly when 
given by the needle. Ergotin (Bonjean) in doses of 2 to 5 grains 
has an excellent effect on the uterine muscle, but acts more slowly 
and more continuously. It is, therefore, well adapted for long- 
continued use and in cases not requiring an immediate rapid con- 
traction of the uterus. 

Hydrastis acts upon the vascular system as a vaso-constrictor 
and causes a general rise in blood-pressure. It has also the power 
to produce uterine contractions. Hydrastis is of value in all 
forms of hemorrhage from the uterus, and has, in addition, a 
stimulating trophic effect on the uterine muscle. The dose of the 
fluidextract is one-half to one dram several times daily. Hydras- 
tinin hydrochlorate is of value in menorrhagia and metrorrhagia 
and also in some cases of dysmenorrhea. The dose is half a grain 
to a grain in capsules several times daily. 

Stypticin fcotarnin hydrochlorate) arrests hemorrhage by an 
astringent action or by directly affecting the blood. It is a hemo- 
static and uterine sedative. It is most efficacious in bleeding not 
due to incomplete abortion or new-growths. It is of especial 
value in prolonged or profuse menstruation. It is also a powerful 
local hemostatic. The dose is 2 to 4 grains four to five times daily. 
A 10 per cent, watery solution can be readily given by the needle. 



184 MEDICAL GYNECOLOGY 

Styptol (cotarnin phthalate) is a hemostatic and sedative, but 
is said to cause a rise of blood-pressure. It is highly recommended 
by Carl Abel as a uterine hemostatic, and especially as a sedative. 
It is used by him (1) in profuse menstruation in young girls and 
nulliparae, (2) in climacteric hemorrhage, (3) in bleeding during 
pregnancy, (4) in the hemorrhage due to myomata, (5) in the 
hemorrhage coming from carcinoma, (6) in dysmenorrhea, being 
then given between the menstrual periods. The drug is best given 
in the original sugar-coated tablets, containing 0.05 gm., five to 
eight times daily. 

Suprarenal extract has some value in uterine hemorrhage in the 
dose of 2 to 4 grains several times a day. Suprarenal extract given 
internally, in addition to its action on the blood-vessels, probably 
causes uterine contraction. Adrenalin solution (1 : 1000) may be 
given in dose of 10 to 30 minims by mouth, or smaller doses by needle. 

Some cases of profuse, continued, irregular bleedings, especially 
when due to myomata, are benefited by the administration of 
chlorid of calcium. 40 grains in solution being given daily to in- 
crease the coagulability of the blood. Milk is to be avoided during 
its use. 

Thyroid extract is sometimes of service in menorrhagia and 
endometritis by diminishing uterine congestion and hyperemia. 
Thyraden may be given in the dose of 2 to 4 grains three times daily. 
The dose of iodothyrin is from 5 to 10 grains three times a day. 

1$. Stypticin gr. ij 

Ft. tal. tabell. no. xx. 

S. — One every two hours. 

1^. Stypticin gr. ij 

Ergotin gr. ij 

Ft. tal. caps. no. xx. 

S. — One every three hours. 

1$. Stypticin gr. ij 

Ergotin gr. ij 

Suprarenal ext gr. ij 

Hydrastinine hydrochlor gr. ss 

Ft. tal. caps. no. xx. 

S. — One every four hours. 

In some cases of long-continued hemorrhage, where stimulation 
of the heart is advisable, digitalis is a drug of value. The infusion, 
especially in the dose of an ounce and a half, is said to cause con- 
traction of the uterus in menorrhagia. 



UTERINE BLEEDINGS 1 85 

In all cases of masturbation efforts directed toward the stopping 
of this habit are of avail only when the patient's attention is called 
to its risks and dangers. Coitus interruptus and excessive coitus 
are conditions to which attention must be paid, for these are ele- 
ments which serve to produce an excessive congestion of the 
genital tract or a congestion not relieved by the sexual orgasm. 

Menorrhagia due to retroflexion may be corrected by reposition 
of the uterus to its normal position. This is best done by the use of 
a Hodge or Smith pessary. The use of the pessary must often be 
preceded by treatment which gradually elevates the uterus and puts 
any contracted ligaments, such as the uterosacral ligaments, on 
the stretch. This is best done by introducing pure boroglycerin 
into the vagina through a bivalve speculum and thoroughly packing 
the posterior fornix with gauze. For this purpose it may be 
necessary to pull the cervix down with the aid of a volsella, or it 
may be necessary to put the patient in the Sims position or in the 
knee-chest position. The anterior fornix and the vagina are also 
packed with gauze. This procedure, carried out three times a 
week, elevates the uterus, diminishes congestion through the eleva- 
tion of the uterus and through the action of the glycerin. When- 
ever the uterus can subsequently be readily brought by bimanual 
manipulation into a normal position, with the cervix high up and 
far back, a suitable pessary may be introduced. It is to be worn 
only if the patient experiences no pain or discomfort. If the pes- 
sary then relieves the annoyances, an Alexander operation or a 
Gilliam operation, or any method which shortens the round liga- 
ments, will permanently retain the uterus in a position which pre- 
vents that congestion which may have existed as a direct result of 
the retroflexion. Stypticin, ergotin, and suprarenal extract should 
be given during menstruation. 

Pyosalpinx, salpingitis, parametritis, and other inflammatory 
conditions about the uterus which produce excessive congestion, 
with or without compression of the blood-vessels, can be medically 
treated by rest and the avoidance of effort, by the wearing of an 
elastic abdominal bandage for the purpose of giving intra-abdomi- 
nal support. Hot douches, for their effect on the pelvic circula- 
tion, are of importance. Sitz-baths containing 3 to 4 pounds of 
sea salt and 3 to 4 ounces of calcium chlorid, taken for a period of 



1 86 



MEDICAL GYNECOLOGY 



fifteen to twenty minutes at body-temperature, a half-hour before 
retiring, have an important action in stimulating the pelvic circula- 
tion and in diminishing edematous and exudative changes. Full 
Nauheim baths, when they can be taken, have a still better action 
than the sitz-baths. At night there should be applied to the 
abdomen a moist flannel bandage covered with oiled silk or with 
chamois skin and left in place during the night (Fig. 105). Three 
times a week boroglycerin should be introduced into the vagina 
through a bivalve speculum and the fornices should be then packed 
with gauze, which is also gently packed into the entire vaginal 
canal. Stypticin in large doses should be given for the bleeding. 

Endometritis of an inflammatory nature is almost always asso- 
ciated with inflammation about the uterus. Whether it is or not, 




Tig. 105. — Abdominal bandage for moist applications to abdomen during the 

night. 



the treatment is the same as that just mentioned for pyosalpinx 
or periuterine inflammation. Stypticin should be given in large 
doses. 

Metritis of an inflammatory character demands the same treat- 
ment as that suggested for periuterine inflammation. In the early 
cases sitz-baths or Nauheim baths are sometimes of very great 
value. 

The removal of retained membranes or placental structures, or of 
part of a placenta or of a complete placenta, demands thorough 
dilatation of the cervix, with or without the splitting of the cervix 
by the Duhrssen method of minor vaginal cesarean section, with 
a thorough examination of the cavity of the uterus (if sufficiently 
large) by the examining finger and a removal of all that is possible 



UTERINE BLEEDINGS 1 87 

with the aid of the finger supplemented by the use of the placental 
forceps and the curet. In those cases where menorrhagia is due 
to probable retention of decidua, ergotin and stypticin should 
be given for several weeks if curetting is refused or contra- 
indicated. 

Endometritis (whether inflammatory or not), which is of the 
character known as glandular or hyperplastic endometritis, should 
be treated by intra vaginal pressure therapy. Pelvic anemia 
should be produced by abdominal applications and by sitz-baths. 
It is particularly in the non-inflammatory cases that ergot, hydrastis, 
styptol, stypticin, and suprarenal extract are of very great value. 
If these fail, curetting can be done, often with marked benefit, 
in the cases that are not inflammatory in nature. In those cases 
in which a uterine or periuterine inflammation is present curetting 
should be done only if the bleedings are so marked as to seriously 
jeopardize the patient's health. It goes without saying that rest 
in bed during menstruation is of great importance. 

Rest in bed and the avoidance of any effort, together with the 
hot-water bag applied to the spine, are very essential procedures 
in the treatment of uterine hemorrhage. Short hot vaginal douches 
are often of value. In some cases of continued menorrhagia ener- 
getic scarification of the cervix before menstruation may diminish 
the amount of blood lost subsequently. In many cases a curetting 
must be done. In those cases associated with hyperplastic endo- 
metrium after curettage subsequent applications to the uterine 
lining are of value. Among the topical applications to the endo- 
metrium are liquor ferri sesquichlorati, pure tincture of iodin, 50 
per cent, solution of carbolic acid in alcohol, 10 to 20 per cent, 
chlorid of zinc. Martin uses 1 c.c. of the iron, injecting it drop by 
drop as the syringe is drawn out. It is well to use a Braun syringe 
covered with cotton. The uterus is then irrigated and gauze is 
placed only in the vagina. 

Subinvolution, when seen in the early stages, demands the use 
of hot douches, vaginal treatment by glycerin and gauze, each 
vaginal treatment being preceded by a thorough painting of the 
vault of the vagina with tincture of iodin. The uterus should be 
made to return to its normal size by continued small doses of ergot, 
ergotol, or ergotin combined with hydrastis, to which preparations 



155 MEDICAL GYNECOLOGY 

stypticin, styptol, and suprarenal extract should be added during 
menstruation. 

Subinvolution after labor or abortion, where the evidences of 
uterine atony are marked, warrants the use of hot vaginal douches 
of i to 3 quarts, cool sitz-baths of a duration of five to thirty 
minutes, massage of the uterus, and, best of all, a complete course 
of Nauheim baths. Malposition should be corrected and there 
should be abstinence for a long period from sexual intercourse. In 
stout women the hyperemia and the associated obstipation should 
be treated by a cure with Glauber's salts associated with the 
application of the sinusoidal current and appropriate diet. 

Passive hyperemia of the uterus furnishes the basis on which an 
inflammatory metritis is easily engrafted. In lymphatic and scro- 
fulous women the uterus often remains large, with a profuse serous 
or mucoid discharge. For this condition salt baths and Nauheim 
baths are especially indicated. The following combination is 
of value : 

ly. Physostigmine salicylates gr. ■£$ 

Ergotin gr. iij 

Euquinin gr. ij 

Strychn. sulph .• g r - ?V 

Ft. tal. caps. no. xxx. 

S. — One t. i. d. for several weeks. 

In non- inflammatory metritis or subinvolution fibrosis we are 
dealing with an end-stage of a previously existing congestion, and 
with structural alterations which diminish the contractile power 
and character of the muscle fibers, of the elastic connective-tissue 
fibers, and of capillaries and vessels of the uterus. Associated with 
this is also a chronic congestive state in the ligaments of the uterus 
and in the pelvic connective tissue and a lack of tone in the general 
circulatory apparatus. The treatment consists in the administra- 
tion of the preparations of ergot, hydrastis, stypticin, styptol, and 
suprarenal extract. Sitz-baths, 50 to 65 , five to thirty minutes, 
or the Nauheim baths, should be given. 

In some cases, those associated with arteriosclerosis, the sitz- 
baths, or even the Nauheim baths, are contraindicated when they 
result in increasing the discharge of blood or in bringing it on at an 
earlier period. In stubborn cases a curetting may be done, followed 
by the application of steam for three to five minutes. Some of the 



UTERINE BLEEDINGS 150. 

cases associated with marked hypertrophy of the cervix are bene- 
fited by a high amputation of the cervix, followed by curetting and 
atmocausis. 

The treatment of those bleedings which are due to arteriosclero- 
sis, with or without enlargement of the uterus, demands also the in- 
ternal administration of ergot, ergotin, hydrastis, stypticin, styptol, 
and suprarenal extract. Very often a curetting followed by a very 
thorough atmocausis must be done. If this fails, hysterectomy 
offers the only relief. 

Bleeding due to fibroids demands the internal administration 
of ergot, hydrastis, styptol, stypticin, and suprarenal extract. If 
these fail, a curetting or the use of atmocausis should be tried. 
In addition to the above-mentioned drugs, the effect of thyroid 
extract should be watched, as its long- continued use, if well borne 
without constitutional annoyances, may diminish the bleeding 
and may even cause some tumors to diminish in size. Some of 
these cases are benefited by the administration of calcium chlorid. 
When these various procedures fail, myomectomy or hysterectomy 
offer the only relief. 

The treatment of endometritis deciduce means rest in bed, 
coupled with the internal administration of stypticin and styptol. 

A rapid loss oj blood is best treated by tamponing the vagina, 
and in some cases the uterus, with iodoform gauze. Hot vaginal 
douches or even irrigations of the uterus may be used with water 
at no° to 120 F. before packing. 

If the cause of menorrhagia is associated with impotence in the 
male or with coitus interruptus, or is produced by use of the sewing- 
machine or by bicycle or horseback -riding, these should be avoided. 
If there is passive hyperemia, obesity, or constipation, salt baths 
are of value after a course of Glauber's salts. Short sitz-baths, 70 
to 85 , five to fifteen minutes, are also of aid. 

In chronic atony of the uterus, found in weak women, in lymphatic 
women, after prolonged lactation, as well as in the form resulting from 
many labors in rapid succession, we use short hot vaginal douches, 
massage of the uterus, ergotin, atmocausis, and no curetting. 

If there is an atonic, soft, thin-walled uterus, we use ergot, bi- 
manual massage, Nauheim baths, etc. 

Climacteric bleedings are best treated by atmocausis. 



I90 MEDICAL GYNECOLOGY 

In bleedings occurring through unrecognized cause, and perhaps 
due to vasomotor disturbances, Olshausen places such patients for 
several hours on a hot sand-bag or a hot-water bag applied to the 
lower vertebrae at no° to 120 F. 

Many of the climacteric bleedings are due to atony or arterio- 
sclerosis. Rest and tamponing of the vagina or the uterus are of 
value. Hot vaginal douches of 2 quarts of water are beneficial. 
Hot applications to the sacrum or a hot sand-bag to the lower 
vertebrae, prolonged cool sitz-baths, strychnin plus euquinin plus 
ergotin, and atmocausis are the best. For the production of 
uterine and pelvic anemia by abdominal applications, by sitz- 
baths, and by electricity see the sections on those topics. 

Treatment of Abortion. — The treatment of inevitable abortion 
consists in reproducing the steps involved in normal labor. In 
labor dilatation of the cervix is aided by uterine contractions 
forcing the "bag of waters" into the cervix, and by the upward 
pull of the cervical fibers around the presenting part of the child, 
as if drawn around a pulley. Continued uterine pains expel the 
contents, and further contractions of the uterus in the third stage 
loosen the placenta and expel it. Therefore the treatment of abor- 
tion consists in aiding dilatation of the cervix, in aiding the separa- 
tion of the ovum and placenta, and in aiding the expulsion of the 
contents. At the same time the interests of the patient should be 
conserved by limiting the hemorrhage as much as possible. The 
very means which are best adapted to preventing an excessive 
loss of blood happen to be the very means which are of the greatest 
value in dilating the cervix. If an abortion is inevitable, and if it is 
desired to carry out the procedure in the simplest manner, the 
following should be done with strictest surgical aseptic precautions. 

The vulva, the vagina, and the cervix should be thoroughly 
prepared. With the aid of a bivalve speculum or with the aid of 
Sims' specula the cervix should be grasped by volsellum forceps, 
and a long strip of iodoform gauze, its width depending on the 
dilatation of the cervix, should be introduced into the cervix and 
as much passed up into the uterus as possible. The cervix should 
then be packed as thoroughly as possible. The vagina, from the 
fornices to the introitus, should be packed with a very wide strip 
of iodoform gauze arranged in plaited form, thus furnishing a 



UTERINE BLEEDINGS ICjr 

packing which completely and solidly fills the vaginal canal. 
With the aid of a T-bandage and gauze about the vulva the vaginal 
packing should be kept in place. Ergot, i dram, or ergotol, J dram, 
should be administered every two or three hours. The vaginal 
packing prevents the exit of blood from the uterus and hemorrhage 
is diminished to a minimum. Through the gauze within the cervix 
dilatation of the cervix is produced. As a result of the packing in 
the vagina and the cervix the blood thus poured out in the uterus 
is retained within it. Contraction of the uterus compresses this blood, 
the poured-out blood dilates the uterus and cervix, accumulates 
between the ovum and the uterine wall, and is an important factor 
in peeling the ovum away from its contact with the uterine wall. 
Contraction of the uterus and the effort of the uterus to expel this 
accumulation of blood dilate the cervix. 

If this packing is removed at the end of twenty-four hours, 
the cervix will be found considerably dilated. The same steps as 
mentioned above should be repeated, but a wider piece of gauze 
should be packed into the uterus, and especially into the cervix. 
The vagina is then thoroughly packed and the use of the ergot is 
continued. It rarely takes more than forty-eight hours with 
this method to dilate the cervix so that it readily admits the middle 
finger. At the same time the ovum and the chorionic villi or 
placenta are often completely loosened from the uterine wall. 
The cessation of uterine pains can generally be taken as proof of 
separation of the ovum. At the end of the forty-eight hours, then, 
the gauze is removed, and not infrequently the ovum is so situated 
that placental forceps introduced into the cervix can grasp and 
remove it — sometimes the fetal sac with the embryo, at other times 
the fetal sac and then the embryo. If the placental forceps do not 
grasp a loosened ovum, chloroform is generally necessary, and the 
middle finger, under the strictest aseptic precautions, is introduced 
into the cervix and uterus; the other hand, pressing through the 
abdominal wall, pushes the uterus down into the pelvis and presses 
on the fundus (Fig. 70). In this way the middle ringer of the 
internal hand can palpate the entire uterine cavity, can separate the 
whole ovum or the adherent parts, or remove whatever of fetal sac 
or placenta is attached. After this procedure the placental forceps 
carefully introduced can extract whatever loosened contents are in the 



I92 MEDICAL GYNECOLOGY 

uterus. The uterus should then receive a very hot douche, with a 
double- running irrigator, of 1 per cent, lysol. If the finger has been 
unable to separate any of the placental tissues, their location at 
least is noted, and placental forceps or a large blunt curet are then 
introduced for their removal. The uterus is then packed with iodo- 
form gauze and ergot is administered. The vagina is" also packed 
with iodoform gauze. The gauze is removed in from twenty- four 
to forty-eight hours and the ergot is continued. In incomplete 
abortion it is rarely necessary to use the sharp curet unless, in 
very early cases, the uterus is so small that the ringer method 
cannot be used. The use of the sharp curet is a dangerous thing: 
first, we are never sure that we have removed all the products of 
conception; second, perforation of the uterus occurs very readily. 
During the manipulation of the curet the uterus dilates and con- 
tracts easily, as it does in the post-partum period at full term, and 
if the curet is held very firmly, simple contraction of the uterus is 
enough to cause perforation by this sharp instrument. 

It is by no means infrequent to find, in abortions at the tenth or 
twelfth week, that an embryo is spontaneously expelled, but decidua, 
the sac of the ovum, or placental remnants are retained. These, 
as a rule, prevent the uterus from returning to normal size, the 
cervix does not contract, and there is generally a steady or irregular 
loss of blood. Under these circumstances the same method of 
dilatation of the cervix by iodoform gauze, and of examination and 
cleansing of cavity with the finger, is very advisable. If this pro- 
cedure is not possible, the dull curet should be used with the greatest 
precaution. In using the curet in the uterus, it is my custom first 
to measure the length of the uterine cavity with a sound, and then 
to place the index-finger of the right hand on the curet at a point 
which makes the distance from the tip of the curet to the finger a 
little less than the length of the uterine canal, as measured by the 
sound. Curettage is then done, with the finger held firmly on this 
point, so that the instrument at no time enters further into the 
uterus than the measured length. The above described method 
of painless, slow dilatation of the cervix by the use of the iodoform 
gauze is the safest and wisest procedure. The above method of 
removing the contents of the uterus by the introduced finger is 
wisest and safest. The finger recognizes adherent tissues. It 



UTERINE BLEEDINGS 1 93 

locates any tissue that cannot be scraped off. It cannot perforate 
the uterus. It makes diagnosis and carries out the treatment. 
It should be used in every case in which the uterus is three 
times the normal size. 

The diagnosis is more difficult when the cervix is closed. The 
continuation of pain speaks for the retention of the ovum or of 
large masses, and bleeding continues. The uterus may be en- 
larged through the thickness of its own walls rather than through 
the size of the contents. The sound may show irregularities or 
roughness in the very early months, but its use causes ready 
bleeding. Winter says that the larger and softer the uterus, the 
more does it speak for the retention of fetal and decidual products. 

The death and retention of the ovum and embryo in the first 
half of pregnancy results in a diminution of the succulence and 
blueness of the vagina and cervix. The uterus becomes harder. 
Bleeding is less frequent than in abortion. The important aid in 
diagnosis is observation of the fact that the uterus does not increase 
in size in the course of several weeks, or that the uterus is much 
smaller than the length of the amenorrhea warrants. The chorionic 
villi may grow after the death of the embryo. Such an ovum is 
found to be covered by thickened decidua. Decidua serotina 
especially is thickened and infiltrated with blood. There is little 
amniotic fluid and the embryo may be present or degenerated. 
Such an ovum has been called bloody mole if fresh blood is present, 
and fleshy mole if decolorized old blood is present. 

In some cases the entire placenta may be retained within the 
uterus. Bimanual examination shows a large uterus, dilated 
cervix, and the diagnosis generally made is submucous fibroid or 
chorioepithelioma. In fact, with very 'adherent placenta examina- 
tion by the finger does not always make the differentiation. Such 
a placenta may be retained in the uterus a year or more, and if it 
undergoes no putrefactive changes the diagnosis is indeed difficult. 
More frequent is the retention of decidua which does not undergo 
involution, but remains as a hypertrophied, hyperplastic lining, 
giving rise to menorrhagia and repeated abortions. 

Most frequent is retention of microscopic fetal cells in the form 
of villi, or the cells which cover the villi, the cells of Langhans, 
and the syncytium. The most frequent causes of repeated abor- 
13 



194 MEDICAL GYNECOLOGY 

tion are syphilis, retroflexion (metritis and fibrosis uteri), and 
especially "endometritis hyperplastica." 

Abortion is most frequent in the third month, when the chorionic 
villi begin to atrophy except at the serotina, the future placental 
site. The danger periods in repeated abortions are the omitted 
menstrual days — the periods when menstruation would have oc- 
curred had no pregnancy taken place. 



LEUKORRHEA 

Leukorrhea represents a discharge of white, yellow, or green, 
thin, thick, or mucoid secretion originating from the vulva, vagina, 
cervix, or uterus. This secretion may represent either a hyper- 
secretion or an inflammatory product. A purulent secretion from a 
urethritis may be accumulated within the folds of the vulva, and 
may cause, in addition to its own accumulation, a chronic localized 
inflammation of the inner surface of the labia, of the vestibule, 
and about the introitus. A purulent involvement of one or both 
of the glands of Bartholin may cause a more or less constant dis- 
charge of pus, to which may be added the secretion resulting from 
an associated vulvitis. Such a secretion is to be noted in chronic 
and acute gonorrheal involvement of the vulva and of the ducts 
and canals which open into the vulva. This condition is most 
clearly exemplified in the gonorrheal vulvitis of children, with 
which a vaginitis is almost invariably combined. In the chronic 
forms of vulvitis not due to the gonococcus there is a reddening of 
the vulva and the secretion may be rather of a serous nature. 

Normal Vaginal Secretion. — The vagina of the newly born is 
sterile only for two or three hours, after which period bacteria are 
present. The normal vaginal secretion contains cast-off squamous 
epithelia and myriads of bacilli. The bacilli present in the nor- 
mal vaginal secretion are short rods, evident to any one who takes 
the trouble to examine a specimen under the microscope. These 
important bacilli are those described by Doderlein, and are held 
responsible for the acid reaction of the normal vaginal secretion. 
This acid reaction is credited with a deleterious action on the 
growth of other bacteria and renders the normal vagina free of 
pathologic germs, destroying within twenty-four to forty- eight 
hours any pathologic cocci or germs introduced experimentally 
into the vagina. The normal vaginal secretion, then, contains 
desquamated squamous epithelial cells, the bacilli of Doderlein, 
and many other micro-organisms, and is of a serous, milky charac- 
ter. 

195 



196 MEDICAL GYNECOLOGY 

Hypersecretion. — A milky serous secretion is characteristic 
of the vagina. As the normal vaginal secretion contains squamous 
epithelia alone, it is wrong to consider any vaginal secretion of this 
nature, even though profuse, as inflammatory. Such a condition 
is often the result of hypersecretion and is noted with pelvic tumors 
and with other conditions which cause pelvic congestion. Hence 
it is particularly marked in pregnancy and in the first few weeks 
after labor. Hypersecretion may be due also to chlorosis, to 
anemia, to onanie, and to excessive intercourse. Hypersecretion 
represents an increase of the normal secretion which is of a 
milky, serous character. There is often a great accumulation on 
the surface of the vagina of drier, white particles consisting of cast- 
off squamous epithelium. 

Bacteria in the Vagina. — There has been and is much differ- 
ence of opinion as to the presence of pathologic bacteria in the 
vagina, some finding streptococci, staphylococci, in a certain 
proportion of cases with pathologic secretion, while others deny 
such findings. It must be remembered that the vulva contains 
numerous bacteria and cocci of various forms. Menstruation, 
masturbation, lack of cleanliness, too frequent douching, inter- 
course, etc., are causes which favor the entrance of these vulvar 
germs into the vagina. We know that bacteria may be introduced 
into the vagina by the manipulation of examination. Their 
growth may be favored by the wearing of pessaries for long periods 
or by the retention of tampons for too long a time, thus really pro- 
ducing a mild vaginitis. The bacterium coli from the rectum, 
especially in women with lacerated perineum, and more so in 
women with tissues of lessened resistance, may find ready entrance 
into the vagina. Latent gonorrhea in the male is productive 
of infection of the vagina, cervix, and uterus, not always 
with the gonococcus, but with the other cocci often present 
in such chronic prostatic conditions in the male. The blood 
expelled in menstruation, after abortion, or after labor diminishes 
the acidity of the vagina and furnishes a medium which furthers 
the development of any bacteria or cocci which are present and 
furnishes a factor which favors their upward extension. 
Therefore it must be said that very often the bacterium coli and 
numerous bacilli and cocci of saprophytic type, together with 



LEUKORRHEA 1 97 

yeasts, are found with pathologic conditions in the vagina, cervix, 
and uterus. In addition, there may be found gonococci, and also 
streptococci and staphylococci. The virulence of the later forms 
differs widely. 

Leukorrhea due to Colpitis. — In addition to squamous 
epithelia, polynuclear leukocytes or pus cells may be present. 
In some women bacteria and saprophytes of various forms grow 
in the vagina and produce a mild vaginitis with marked desquama- 
tion of squamous epithelia, especially in warm weather. In such 
cases we note the presence of numerous forms of bacteria. They 
may be found in such variety and large numbers that they give 
the picture of a pure culture. The vagina on close examination 
may show a diffuse reddening or it may be covered with multiple 
small red granular spots. Other cases show isolated areas of dark 
red or blue character with a dilatation of fine venous channels. 
Associated irritation of the external genitalia is sometimes evident 
to the eye, and is due either to this vaginal factor or to scratching, 
which causes an added irritative condition. It is necessary to note 
the cause, and to differentiate the local vulvar changes due to the 
causal factor from the external changes brought about by scratch- 
ing or irritating treatment. In many cases no external or internal 
lesions are evident, the only symptom being a profuse vaginal dis- 
charge. Often changes probably have been present, and having 
run their course only the discharge remains. The Ferguson 
speculum should be used in noting the character of the vaginal 
mucosa. 

In gonorrheal vaginitis there is a discharge of purulent secretion 
containing pus cells and gonococci. Primary gonorrheal vaginitis 
in adults is not frequent, but in children always accompanies a 
gonorrheal vulvitis. The vaginitis of gonorrheal origin is generally 
secondary in this sense, namely, that it is caused by the discharge 
of gonococcus-bearing secretion from the cervix and uterus, which, 
by constantly bathing the vaginal mucosa, finally causes a vaginitis 
which is most marked in the posterior fornix and on the posterior 
wall of the vagina. The vagina may be diffusely red and granular 
and may show loss of epithelium in certain areas, especially in the 
posterior fornix. Gonorrheal vaginitis is more intense in pregnant 
women. 



198 MEDICAL GYNECOLOGY 

The discharge in every case of leukorrhea should be examined 
microscopically to determine the forms of bacteria present. In 
examining vaginal secretions we may find, besides the bacilli of 
Doderlein, other bacteria. In addition, leukocytes or pus cells 
may be present. The greater the number of leukocytes, the 
greater is the inflammatory reaction. 

A milky serous discharge is present with mild colpitis. A green 
or yellowish-green discharge coming from the vaginal wall is 
gonorrheal. Colpitis is to be diagnosed by the character of the 
vaginal secretion and by changes in the mucosa. If pus cells are 
found in the vaginal secretion, admixture of the pus from the cervix 
or uterus must be excluded by use of the Schultze tampon. Pus 
cells in the vaginal secretion mean inflammation. 

Hypersecretion from the Cervix. — In many women, especially 
unmarried, there is a profuse hypersecretion of clear tenacious 
mucus from the cervix. This may result from congestion, from 
masturbation, or from displacement of the uterus. It is not an 
abnormal secretion in character. The microscope shows mucus 
and a few cast-off epithelial cells. A pathologic secretion is white, 
yellow, or green, and consists of mucus, epithelia, and polynuclear 
leukocytes or pus cells. 

Leukorrhea from Erosions. — Erosions represent a substitu- 
tion of the squamous epithelium of the vaginal portion of the cervix 
situated about the external os by cylindrical epithelium of the 
cervical canal. Erosions are almost invariably due to an asso- 
ciated cervico-uterine catarrh. The erosion itself produces a 
catarrhal yellow secretion, especially if of the glandular type. 
Since the erosions are due to cervical or uterine discharge (often 
gonorrheal), the amount of mucoid secretion discharged from the 
cervix may be very marked. 

Leukorrhea from Endocervicitis. — In the acuter forms of 
endocervicitis due to gonorrhea the discharge is of a greenish and 
later of a yellowish character. It consists of pus cells. A typical 
cervical discharge is always mucoid, but there are cases of gonor- 
rheal involvement of the cervix and uterus in which the cervix 
does not react by the production of much mucus and yet the lining 
of the cervix is inflamed and reddened. In such cases it is hard to 
distinguish between the discharge which comes from the cervix 



LEUKORRHEA 1 99 

and that which comes from the uterus. Acute endocervicitis 
may be followed by some hypertrophy of the cervix, and later on by 
erosions. In the most frequently observed form of cervical inflam- 
mation we have what is known as a chronic endocervicitis, charac- 
terized by a discharge of whitish, thick mucus and by hypertrophy. 
There may be present on the vaginal portion of the cervix the so- 
called follicles of Naboth, which represent either a dilatation of 
cervical glands which have grown through the cervix up to the 
squamous epithelium, or else they represent dilatation of the 
glands present in an erosion. This condition of chronic cervical 
catarrh is very frequently associated with an involvement of lymph- 
atic connective tissue situated in the posterior parametrium and 
in the uterosacral ligaments. This involvement of the post-parame- 
trium is most marked in those cases originally gonorrheal or 
originally septic after abortion or labor. In this chronic and very 
frequent form there is often an eversion of the lips of the cervix 
when they are torn laterally. The everted mucous membrane 
may be red and swollen and produces much discharge. In chronic 
endocervicitis we have a catarrh of the cervix due to chronic inflam- 
mation and irritation by bacteria of various forms and producing 
a white or yellow stringy mucoid secretion, often very thick and 
tenacious, and often forming a plug which may completely fill 
the dilated cervical canal. A mucoid discharge comes only from 
the cervix. 

Leukorrhea Coming from the Uterus. — Even in puerperal 
women free of fever a certain small percentage show streptococci, 
staphylococci, gonococci, and bacteria in the lochia. The relative 
proportion of the infecting bacteria in puerperal endometritis, 
according to Kronig, shows 2 per cent, staphylococci, 27 per cent, 
saprophytes, 27 per cent, gonococci, and 43 per cent, streptococci. 
The fatal cases are due to streptococci. 

It is claimed by some that bacteria are present in chronic hyper- 
plastic endometritis, but Doderlein says that this is not so. Peraire 
found bacteria in all cases of endometritis and metritis, among 
them a bacillus and a coccus which in pure culture caused inflam- 
mation in the vagina of rabbits and the uteri of dogs. Doderlein 
says that this is no proof that they would do so in the human being. 
Brandt in twenty-five cases of endometritis obtained the curetted 



200 MEDICAL GYNECOLOGY 

particles and found cultures in twenty-two. In one-third of these 
he got streptococci and staphylococci pyogenes aureus and albus. 
These Doderlein calls an accidental infection of the media. Pfan- 
nenstiel and Menge obtained negative results by tests like Brandt's. 
Bumm in fifteen cases of endometritis found bacteria by cultures. 
He says that they are not the cause but are only added factors. 
Menge in seventy-three uteri examined the fundus in seventy-three 
and the cervix in twenty-nine, and found only six cases with bac- 
teria. Among these were cervix carcinoma, a submucous myoma, 
and a case of tuberculosis. The corpus mucosa in seventeen was 
normal, in twenty-nine was hyperplastic or hypertrophic, in twenty- 
one inflammatory, that is, there was small-celled infiltration. 
Examination of the cervix mucosa showed ten normal, ten hyper- 
plastic or hypertrophic, and nine inflamed. 

We must distinguish two forms of "endometritis" — a non- 
inflammatory and an inflammatory. The non-inflammatory 
represents simply a hyperplasia of the endometrium, i. e., an 
overgrowth. It is characterized by menorrhagia and discharge 
is not a symptom. In the inflammatory form we have round-celled 
inflammatory involvement of the endometrium, sometimes diffuse, 
more often localized or scattered, sometimes deep, but more often 
superficial. It is characterized not by menorrhagia but by dis- 
charge and by pain. 

Uterine leukorrhea means, then, a discharge from the uterine 
canal of a serous, sero-purulent, or purulent secretion containing 
epithelia and polynuclear leukocytes or pus cells. It is divided 
into the forms known as gonorrheal and catarrhal. The gonorrheal 
form implies the finding of gonococci, yet in many cases where the 
yellow or green discharge contains nothing but pus cells, the gono- 
cocci cannot be found. A discharge containing epithelia and pus 
cells, and light or white in color, may represent the end-stage of a 
gonorrheal invasion, or may be due from the beginning to other 
bacteria. 

A white discharge from the uterus, containing epithelia and 
leukocytes and no gonococci, is known as catarrhal endometritis. 

Not every inflammatory condition of the endometrium is charac- 
terized by profuse discharge. The secretion cast off from the 
uterine lining may be slight in amount or even absent, in spite of 



LEUKORRHEA 201 

well-marked inflammatory changes. A Schultze tampon must be 
left in place for twenty- four hours, and by its use the uterine dis- 
charge is collected, is differentiated from the cervical mucoid 
discharge, and contamination by vaginal secretion and bacteria is 
avoided. Fig. 12 and Fig. 13 show the apparatus by which the 
secretion of the cervix and uterus may be obtained for examination. 

In older women there is noted a sero-purulent discharge due to 
growth of bacterium coli or of saprophytes, and is often associated 
with the vaginal involvement known as senile vaginitis. Senile 
vaginitis implies the growth on non-resistant tissues of bacilli or 
cocci which are normally held in check by resistant epithelium 
and by the normal acid vaginal secretion. The discharge in senile 
endometritis may be associated with a disagreeable odor. Carci- 
noma should always be suspected. 

A degenerating fibroid may result in the discharge from a uterus 
of a disagreeable secretion with foul odor. Beginning carcinoma 
is characterized by a serosanguineous discharge. Tuberculosis 
of the endometrium (a rare condition) may produce a purulent 
secretion. Degenerating carcinoma of the vagina, of the cervix, 
or of the uterus produces a discharge of typically foul odor. Wait- 
ing for such a diagnostic sign means almost invariably an inoperable 
malignant infiltration and degeneration. Any discharge from the 
vagina, cervix, or uterus, whatever its color, quantity, or charac- 
ter, in women about forty or after forty, especially if of a fouL 
nature, and more especially if it comes on after a period of climac- 
teric amenorrhea, should be viewed as due to a malignant growth 
until most thorough investigation proves it to be due to another 
cause. 

TREATMENT OF LEUKORRHEA 

When first seen, every case evidencing vulvitis should have the 
vulva thoroughly washed with glycerin-soap and water, making 
use of cotton sponges. Treatment of the vulvitis demands abso- 
lute cleanliness and the correction of the cause. If it is secondary 
to conditions existing in the urethra, bladder, vagina, cervix, or 
uterus, these affections must be treated. In addition to the pre- 
liminary washing, the vulvitis itself is benefited markedly by warm 
sitz-baths taken twice daily for a period of fifteen minutes. Shav- 



202 MEDICAL GYNECOLOGY 

ing of the parts, if the skin area is involved, is of great value. 
Twice daily a douche should be taken consisting of i dram of 
acetate of aluminum to 2 quarts of water. 

Vulvitis associated with jresh gonorrhea should be treated by 
cleansing of the external structures. Mild solutions of corrosive 
sublimate, 1 : 5000 to 1 : 10,000, should be used. The parts 
should be carefully separated and gently sponged with cotton 
soaked in this solution. Bichlorid gauze should then be placed 
in such a manner that the two sides of the vulva are well kept 
apart. A gentle T-binder should be applied. The vulva should 
be washed in this manner several times daily, each washing being 
preceded by a vaginal douche of bichlorid of mercury, 1 : 2000. 
The patient should be kept in bed, laxatives should be administered, 
and urotropin and salol, 5 grains of each, should be administered 
four times a day. If the skin is sensitive and red and is irritated 
by the action of the bichlorid of mercury, the gauze dressing should 
be saturated with a J per cent, solution of acetate of aluminum. 
In the subacute stage the vulva should be treated by the silver 
salts. It should be painted with argyrol 25 per cent., or by nitrate 
of silver 5 to 10 per cent., and the surfaces should be kept dry by 
gauze or dusted with dermatol or nosophen. 

In gonorrheal vaginitis the vagina, if not too sensitive, should be 
washed with the aid of a Ferguson speculum with sponges soaked 
in a carbolic solution, and gauze soaked in 1 to 5 per cent, protargol 
should be introduced into the vagina, especially into the posterior 
fornix, and left in place for several hours. Still later the vagina 
should be bathed, with the aid of a Ferguson speculum, by solutions 
of nitrate of silver 1 per cent., and the vagina should be gently 
packed with sterile gauze or iodoform gauze left in place for twenty- 
four hours. Then irrigate daily with alum 2 per cent., or per- 
manganate of potash 1 : 1000. In the chronic persisting forms 
of gonorrheal vaginitis the Ferguson speculum should be used and 
nitrate of silver should be applied in stronger solutions. In the 
acute stages of vaginitis douches should be cool, in the subacute 
stages tepid, and in the chronic stages warm. 

In very chronic cases if silver 1 per cent, or stronger fails, paint 
the vagina every two or three days with tincture of iodin or silver 
5 to 10 per cent., and pack the vagina with iodoform gauze. Con- 



LEUKORRHEA 203 

tinue the treatment till vaginal epithelium desquamates. Douches 
should then consist of tannic acid, sulphate of zinc, or alum, i 
dram to the quart. Splendid results are to be had by bathing the 
vagina with the aid of the Ferguson speculum with bichlorid of 
mercury i : ioo, rendered acid by a few drops of hydrochloric acid. 
Then pack with iodoform gauze and repeat twice a week. In the 
meantime irrigate with i : 5000 to 1 : 2000 bichlorid. 

In that chronic form known as colpitis granulosa, first clean the 
vagina with the aid of the Ferguson speculum, and then use pure 
pyroligneous acid in the Ferguson speculum, rubbing it well into 
the vaginal mucosa with cotton on a swab. This should be done 
two or three times a week. 

Senile Vaginitis. — Bathe the vaginal walls thoroughly with 
pyroligneous acid three times a week for several weeks through 
the Ferguson speculum. Daily douches of pyroligneous acid 
3 to 5 drams to the quart are to be given. No pessary is to be 
worn. 

For colpitis mycotica 1 per cent, corrosive sublimate or 3 per 
cent, carbolic should be applied with the aid of the Ferguson 
speculum. 

Leukorrhea 0} Virgins. — In the treatment of vaginal hypersecre- 
tion in young virgins cure of the chlorosis often corrects the fluor. 
If correction of the chlorosis does not cure the fluor, cool sitz-baths 
increase the tone of the capillaries. If bacteria have developed on 
the basis of this condition, astringent vaginal irrigations are neces- 
sary. Arsenic and iron are of value. The catarrhal conditions 
occurring with chlorosis, anemia, and run-down conditions are 
due to anemia and to transudation prompted by the hydremic 
state of the blood. If venous stasis is present in the pelvic organs, 
a vaginitis may occur, and does so not rarely in obese girls. For 
the relief of this condition saline waters internally should be used 
to act on the intestines and Nauheim baths should be given. 

DOUCHES IN VAGINITIS. 

1^. Acidi tannici oiss 

Zinci sulpb oiss 

S. — oij to quart. 

1$. Acidi pyrolign §iv 

One tablespoon in quart water. 



204 MEDICAL GYNECOLOGY 

1$. Pulv. aluminii acetatis O ij 

3j to quart. 

Iy. Acidi tannic §ij 

Glycerini § vj 

One or two tablespoons to quart. 

1$. Acidi borici § j 

Pulv. alum § j 

Zinci sulph §j 

3ij to quart. 

Many cases of chronic vaginitis show almost no local changes,, 
aside from hyperemia, but are characterized by a more or less 
profuse leukorrhea. The following is a fair routine treatment 
for the average case. A Ferguson speculum should be used, for 
it is the only means of furnishing us with a distinct view throughout 
the length of the vaginal canal. The vagina is washed thoroughly 
with cotton in sponges soaked in a i per cent, solution of lysol. 
Then there is poured into the speculum a i per cent, solution of 
bichlorid of mercury rendered acid by the addition of a few drops 
of hydrochloric acid. By moving the speculum forward slowly, 
the entire vaginal canal is bathed for one minute, and then dried by 
cotton. 

As a rule, vaginitis is best treated by the dry method after the 
Ferguson bath. This is accomplished by introducing through 
the speculum dermatol powder with the powder-blower or tanno- 
form, or by introducing a long tubular tampon dusted with derma- 
tol or with tannoform and talc equal parts, or with alum and boracic 
acid in the proportions of i of alum to i of boracic acid down to i 
of alum to 4 of boracic acid, the tampon being left in place for 
twenty-four hours. Alum has a mild corrosive action. 

When a decided astringent effect is desired and glycerin is to 
be used, boroglycerin may be substituted by ichthyol-glycerin 
(5 per cent.) or by tannic acid and glycerin (2 to 5 per cent.). 
The vagina at the end of twenty-four hours should be irrigated 
by one or two daily douches. Boracic acid, 2 drams to the quart,, 
forms simply a mild cleansing douche, while acetate of aluminum, 
1 to 2 drams to the quart, is soothing and healing. In the douches, 
tannic acid, 2 drams to the quart, is an astringent of value with 
excessive secretion. Alum, 1 dram or 2 drams to the quart, also 
has an astringent action. Carbolic acid 1 dram to the quart, 
bichlorid 1 : 5000 to 1 : 1000, creolin, lysol, etc., are cleansing 



LEUKORRHEA 205 

antiseptics. Pyroligneous acid, one tablespoon to the quart, 
is very good, but the odor is rather annoying. 

Another method of treatment by the aid of the Ferguson specu- 
lum is a thorough washing of the vagina by any mild antiseptic 
solution with the aid of cotton in a sponge-holder. The vagina is 
then dried and the entire canal is then given a Ferguson bath with 
pyroligneous acid or with tincture of iodin, or with a i per cent, 
silver solution, care being taken not to let any of the fluid flow 
out over any of the external structures. The vagina is then dried 
and an ounce of boroglycerin is poured in through the speculum 
and the vagina is packed with gauze. The glycerin exerts its 
action on the cervical lining, and in the course of time clears it 
of its mucous catarrh. 

The various preparations mentioned above are to be used as 
douches. The gauze tampon or the gauze packing is always 
removed by the patient after twenty-four hours. 

This treatment should be repeated two or three times a week, 
care being taken to avoid irritation of the mucosa, especially when 
using corrosive sublimate. 

Patience is needed in the treatment of cervical erosions and cervi- 
cal catarrh, as their cure not infrequently takes several months. 
It is not sufficient to make local applications to the external sur- 
face of the cervix. The associated cervical catarrh must be treated 
and cured. The best form of treatment is the application of pure 
carbolic acid by cotton applicator to the entire erosion area. The 
application is allowed to remain for only a few seconds if the ero- 
sions are superficial, but if the erosion is papillary or glandular, 
the carbolic acid must be allowed to act longer, the idea being to 
destroy the ciliated epithelium which is growing in the area nor- 
mally covered by squamous epithelium. Pure tincture of iodin 
is then applied to the entire cervical covering and to the vault of the 
vagina. The alcohol in the iodin tincture neutralizes the further 
action of the carbolic acid and the iodin is applied for its alterative 
and antiseptic properties. An ounce or more of boroglycerin is 
then poured into the vagina and the vagina is packed with gauze, 
which is thoroughly packed into the fornices. The gauze is re- 
moved at the end of twenty-four hours and vaginal douches are 
given twice daily consisting of 3 to 4 tablespoons of pyroligneous 



206 MEDICAL GYNECOLOGY 

acid in 2 quarts of water, or any of the above-mentioned powders. 
The applications to the cervix of iodin are made three times a week, 
the carbolic acid being applied once or twice a week, according 
to the degree to which the ciliated epithelium has been destroyed. 
Unless the ciliated epithelium is entirely destroyed (and not too 
deeply at any one time in order to avoid much loss of tissue) 
the erosion will not heal. When healing takes place, the squa- 
mous epithelium is seen to gradually grow in from the edges. 
In the later stages its growth may be stimulated by the local appli- 
cation of nitrate of silver from 1 per cent, up to 5 per cent. It 
may be done once or twice a week. . The purpose of the boro- 
glycerin treatment is to draw out the cervical mucus and to draw 
out the cervical inflammation from the very depths of the glandular 
recesses. When the canal becomes clearer and the mucus becomes 
colorless, the lining of the cervix may be gently painted with tinc- 
ture of iodin or with 1 per cent, nitrate of silver. 

In the treatment of erosions stubborn cases must be painted with 
50 per cent, solution of chlorid of zinc. In other cases the erosion 
must be painted with pure pyroligneous acid or with pure formalin, 
followed by the boroglycerin treatment. By some the cervical 
canal in stubborn cases is gently cleared of its mucus and is painted 
with 10 per cent, silver or with 10 per cent, solution of chlorid of 
zinc. In my experience the avoiding of intracervical treatment is 
followed by good healing results and no induration, inflammation, 
or stricture of the canal takes place. 

If follicles are present, they should be opened, the mucus squeezed 
out, and the little recess should then be touched with carbolic acid 
followed by iodin. 

A distinction must be always made between erosions and ectro- 
pion, for ectropion does not yield to this treatment. Ectropion 
simply represents the everted mucous membrane of the cervix, 
when deep lateral tears are present. Hence ectropion is found only 
in women who have borne children, while erosions are present in 
nulliparae or multiparas, most frequently in the former. In cases 
with marked ectropion or in erosions of the cervix associated with 
diffuse hypertrophy, especially where the cervix is rilled with 
dilated follicles, high amputation of the cervix gives an immediate 
and satisfactory result. 



LEUKORRHEA 207 

The treatment of acute gonorrheal endometritis means rest in 
bed until temperature is normal for three weeks; the bowels should 
be kept open. The diet should be fluid and ice-bags should be ap- 
plied to the abdomen. For the pain an opium suppository should 
be used. Hot vaginal douches of bichlorid of mercury i : 5000 
should be given three times daily. Dry bichlorid gauze should 
be applied to the vulva and the parts should be kept separated. 

In treating cervical gonorrhea Bumm makes incisions in the 
external os, if it is narrow. When the incisions are healed, he 
clears the cervix of mucus and applies 1 to 5 per cent, silver nitrate 
at one sitting, until the whole lining becomes white. Ichthyol 
5 to 10 per cent, is then applied on cotton or gauze. When the 
resulting membrane finally comes away, he repeats the cauteriza- 
tion with silver or with chlorid of zinc, and ofttimes the case gets 
well. If it does not heal, or if there are signs of endometritis, he 
treats the uterus carefully, unless the adnexa have been recently 
affected. If this is the case, he lets even the cervix alone, for care 
should be taken to avoid extension to the tubes. 

He begins intrauterine therapy, even with women who have had 
children, with dilatation of the internal os by laminaria in order 
to get good drainage. Then he swabs out the secretion and 
applies 1 per cent, silver or 1 to 3 per cent, ichthyol with Play fair 
sounds covered with cotton. He makes the applications for ten 
minutes. Injections with a syringe are not advisable. He also 
uses daily irrigations with a double-running catheter for fifteen 
minutes to wash out all the folds of the endometrium. He uses 
silver 1 : 1000 or ichthyol 1 : 100. Sometimes the cocci disappear 
very soon, but sometimes they reappear after treatment is stopped, 
in which event treatment must be continued for weeks. 

When there is a chronic uterine gonorrhea with many squamous 
epithelia in the secretion and cocci in groups on the epithelia, 
stronger solutions must be used, such as tincture of iodin, silver 
10 to 20 per cent., or strong chlorid of zinc. The resulting strong 
reactions after such a thorough cauterization, which should be 
done only once a week, throw off the cocci. If fever occurs on the 
day of treatment, or if there is increased sensitiveness of the uterus, 
treatment should be stopped for a while (Bumm). 



208 MEDICAL GYNECOLOGY 

In chronic inflammatory endometritis intrauterine treatment is 
capable of very great harm. I do not follow Bumm's method. 

A catarrhal endometritis not associated with hemorrhage should 
not be curetted. The treatment is the same as that of cervical 
catarrh. An important aid is the use of glycerin in the vagina, best 
applied with the aid of gauze. A very good procedure consists of 
the use of douches of several quarts of cold water, beginning first 
with tepid water and gradually cooling it down in the course of 
weeks. When continued for weeks, it has a hardening effect. 
This treatment is far safer than dilatation of the cervix with Hegar 
dilators or with Weir's sounds, and irrigation with i per cent, 
lysol, i to 2 per cent, carbolic, i : 3000 sublimate, or \ ounce of 
Lugol's solution to the quart of water. These irrigations are 
done two or three times a week. Later on, with a wide cervical 
canal the uterus is irrigated and tincture of iodin or 5 to 
10 per cent, chlorid of zinc is applied. In other instances medi- 
cated sticks containing iodoform or protargol are introduced 
into the uterus two or three times a week. In other cases steam 
has been used with fair results. In the treatment of chronic and 
subacute gonorrhea, although some dilate the cervix and make 
use of the above methods, it is wiser to use no intrauterine treat- 
ment. Every stubborn uterine catarrh which resists treatment is 
probably gonorrheal. We then depend on the use of the cold 
douche cure, the use of boroglycerin and gauze, the administration 
of sitz-baths, suction (Fig. 13), the use of tonics, and such an arrange- 
ment of the patient's life as will increase her physical resistance. 

In gonorrhea in pregnancy there should be no treatment, ex- 
cept perhaps douches, and the patient should stay in bed four to 
five weeks after labor, until complete involution takes place. 

Senile endometritis demands treatment of the associated vagini- 
tis. This is accomplished by washing the vagina three times a 
week with pure pyroligneous acid applied through the Ferguson 
speculum. Douches consisting of 1 tablespoonful of pyroligneous 
acid to the quart of water should be taken once or twice daily. 
For the endometritis itself intrauterine irrigations of 1 per cent, 
carbolic acid are the best. The uterus must be hardened or made 
resistant to the action of the bacteria. This is best accomplished 
by the use of tepid water, and later on cold water, in the employ- 



LEUKORRHEA 200. 

ment of the vaginal douches, the temperature being gradually 
diminished in the course of a few weeks. The douches should be 
copious and consist of several quarts. 

In all cases of catarrhal secretion from the uterus associated 
with descent of the uterus or with retrodisplacement, especially if 
the uterus is large, a pessary should be eventually introduced. In 
addition, pelvic congestion should be corrected by sitz-baths, 
Nauheim baths, and the use of the sinusoidal current applied to 
the abdomen. Constipation should be corrected by the mechanical 
methods mentioned in the section on Constipation, for all these 
procedures diminish pelvic congestion and stasis and aid in 
establishing a better general circulation. The use of the pessary 
is, of course, contraindicated with periuterine inflammation. 

In this condition especially, and in all intrauterine discharge, 
whether of a serous or a serosanguineous or purulent nature, and 
most especially if the discharge has a fetid character, the existence 
of carcinoma must be considered. Carcinoma of the uterus may 
remain for months, and even years, more or less localized to the 
uterus and with very late extension into the connective tissue of the 
broad ligament. In the early stages especially enlargement of the 
uterus is not present. The diagnosis can be made by uterine scrap- 
ings, repeated if the symptoms persist and if hemorrhage continues 
or becomes worse. 



14 



PRURITUS VULVAE 

Pruritus vulvae is generally known as an affection of the external 
genitalia, characterized by the sensation of burning and itching 
and biting. The itching is only a symptom of a diseased general 
or local state. It has been commonly divided and classified, 
according to the cause, into a constitutional, a nervous, and a local 
form. Constitutional forms are due to icterus, diabetes, gout, 
or intestinal toxemia. The pruritus vulvae due to a general condition 
such as icterus is only part of a general pruritus and evidences no 
local change, but when due to diabetes is generally characterized 
by a typical local alteration of color and character and by local 
annoyances. 

The changes in the character and color of the labia and vulva 
are so typical in the pruritus associated with diabetes that when 
well marked they cannot be mistaken. The entire skin or mucous 
covering of the larger and especially of the smaller labia and 
the clitoris has a thickened, shiny, leathery, glazed look. There is 
a suggestion of solid edema, but the bronze or copper color is char- 
acteristic. Occasionally there is only furunculosis. 

In the vulva as well as in other parts of the body errors in metab- 
olism and gouty or other diatheses may be at the bottom of various 
eczematous skin changes. A local eczematous change may pro- 
duce redness and swelling of the labia majora, minora, and vesti- 
bule, and may extend out to the groins. In the moist form the 
parts are agglutinated; in the dry form they are not. 

The nervous form of pruritus, if local, is due to involvement of 
the nerve- ends in the vulva, but is without evidence of primary 
local inflammation or alteration, and represents changes in the 
nerve-ends like those that occur in neuralgia. According to 
Webster, there is a fibrosis of the nerve- ends. 

Aside from this fibrosis of the nerve-ends, local forms of pruritus 
are due to irritations, to vulvitis or vaginitis, to cervical catarrh, 
to uterine discharge, and to skin affections. 



PRURITUS VULV^ 211 

Pruritus may result from masturbation. Onanie may affect the 
sebaceous glands on the inner surface of the small labia and in the 
vestibule. There is often evidenced a lengthening of the labia and 
clitoris, and also a granular uneven character of the surface of the 
small labia and the vestibule. The vestibule may be greatly con- 
gested. The itching ceases only when masturbation is stopped. 

Local uncleanliness, perspiration, or contact of the parts may 
cause an intertrigo or sore condition of the skin. A dermatitis, 
especially in fat women, may be present on the inner surface of the 
thighs and may spread to the vulva. An acute dermatitis is pro- 
duced by chemical or other irritation acting on the skin, and 
improves on removal of the cause. 

Intertrigo is characterized by its occurrence at points of contact 
of skin surfaces. There is at first a marked secretion from the skin 
glands and a maceration of the epidermis. Then the skin becomes 
dark red, moist, warm, and sensitive. There is no sign of inflam- 
mation. There are heat and pain. On this basis an eczema 
readily develops. 

Eczema is a chronic, itching, desquamating skin affection which 
is either moist (serofibrinous exudation) or dry (growth of epider- 
mis or fatty secretion). 

The irritation of abnormal urine, especially urine containing 
bacteria, or ammoniacal urine, may cause itching. In reviewing 
the history of numerous cases, especially but not always the milder 
forms of pruritus vulvae, it is noted that patients mention a fre- 
quency of urination by day and by night. Close examination often 
discloses the fact that urinary annoyances and vaginal discharge 
were noted at the same time. This concomitant bladder condition, 
known as irritable bladder, must be distinguished clinically from 
the severer forms known as cystitis. That certain forms of pro- 
found cystitis cause a most decided vulvitis and pruritus is no novel 
statement. The connection between urinary disturbances of a 
milder character and the milder forms of pruritus is evidenced by 
the result of treatment, and this form furnishes us with a most 
gratifying percentage of cures. Now that we consider irritable 
bladder likewise due to a local pathologic condition, we must 
credit the urine and its contained bacteria with the power of pro- 
ducing external local vulvar irritations. 



212 MEDICAL GYNECOLOGY 

There are cases in which the rectum is perhaps the causal in- 
fluence, for it is quite certain that after constipation, especially on 
the use of enemata, or after diarrhea, the means of infecting cer- 
tain areas of the genital tract are present. This is often the case 
in older patients with lacerated perineum and in those careless 
as to personal cleanliness. This factor plays a part in infecting 
the bladder. 

Pruritus is generally present with acute gonorrheal vulvitis. It 
is often present with other forms of vulvitis. It will be found that 
marked lesions are sometimes present and often absent. There 
may be diffuse reddening of the external genitalia. The smaller 
labia may evidence a hypersecretion of the sebaceous follicles or 
there may be a minute granular roughening or smaller or larger 
lesions resembling herpes or pemphigus. In chronic vulvitis 
changes may take place in the papillary bodies and produce evident 
alterations in the fossa navicularis, in the hymen, or about the 
urethra. 

Local alteration is present in the pruritus so often found in the 
climacterium, which is experienced as a burning and itching, es- 
pecially annoying at night. There is in particular a local change 
which affects the smaller and the larger labia and the clitoris. 
This typical form associated with visible alterations is known as a 
vulvitis pruriginosa. Pruritus is also a symptom of the rare local 
atrophic condition known as kraurosis vulvae. 

In kraurosis there is an atrophic condition of the corium of the 
larger and smaller labia and of the introitus. There are seen 
white spots on the surface, which later takes on a sclerotic character. 
The mucous membrane becomes gray, white and atrophic, and the 
smaller labia and the clitoris shrink. The larger labia appear flat 
and the smaller labia seem almost absent. Narrowing of the intro- 
itus results. 

Kraurosis vulvae differs from vulvitis pruriginosa in two respects : 
(i) There is a decided narrowing of the introitus; (2) the atrophic 
condition of the skin is marked. In vulvitis pruriginosa the skin 
is not atrophic, but is folded and red or bluish in color. 

Pruritus vulvae is often secondary to irritation produced in the 
vagina by the gonococcus, the leptothrix vaginalis, the oidium 
albicans, by the bacterium coli, etc. Inflammation of the vagina 



PRURITUS VULViE 213 

in the early stages shows a red vagina, red papillae, and discharge. 
A frequent form of pruritus vulvae, then, is that due to vaginal 
non-gonorrheal leukorrhea of the nature of hypersecretion or of an 
inflammatory character. In younger women acute vaginitis is in 
almost all cases gonorrheal in etiology. When pruritus is present 
with an acute gonorrheal affection, it is of little importance in 
making the diagnosis, for other conditions attract the greatest 
attention. When, however, the acuteness of the condition has 
passed, isolated remains of the local alterations are of corroborative 
value. A purulent urethritis, spotted areas of redness on the vulva, 
infection of the glands of Bartholin, the flea-bite redness about 
the opening of the ducts of Bartholin, red eroded areas in the 
fourchet, small red papillary areas in the vagina, and inflammatory 
involvement of the cervix all speak for the gonorrheal nature. 
After the acute condition is gone, such evidences may be entirely 
absent, however, below the cervix, and yet pruritus is present. 

We must also distinguish and bring into a separate class the 
senile form of vaginitis, in which there is often a diffuse, red, irrita- 
tive or non-ulcerative condition due to the growth of bacteria on 
senile tissues of lessened resistance. The bacteria producing such 
conditions do not, as a rule, produce these irritations in younger 
women with more resistance epithelium. The bacteria coli, 
together with yeasts, are probably important factors in the pro- 
duction of this senile condition of which pruritus is a symptom. 
The wearing of rings to relieve prolapse or cystocele always in- 
creases the vaginal irritation and increases the pruritus. 

Pruritus may be the result of a discharge coming from the cervix 
or uterus. Catarrh of the cervix or uterus may produce a secre- 
tion of an exceedingly irritative nature. With an originally sub- 
acute involvement of the cervix, local objective vaginal and vulvar 
signs are generally absent, and pruritus in a certain number of 
cases may be the only symptom, and the discharge the only objec- 
tive evidence. 

Another cause of leukorrhea and pruritus, but itself probably 
due to bacterial influence, is erosion of the cervix, which is always 
associated with an endocervicitis. 

Uterine leukorrhea due to catarrhal or gonorrheal endometritis, 
and the secretions resulting from a degenerating fibroma or from 



214 MEDICAL GYNECOLOGY 

a carcinoma of the cervix or uterus or associated with senile endo- 
metritis, are capable of causing pruritus vulvae or vulvitis. 

In pregnancy an increased vaginal secretion containing bacteria 
of various forms is productive of vulvar itching and burning. 



TREATMENT OF PRURITUS 

Pruritus due to pediculi should be treated by a shaving of the 
parts and by the application of blue ointment or gauze soaked in 
i : iooo corrosive sublimate. 

If the pruritus takes its origin from the rectum, cleanliness is 
essential, and the anal area should be thoroughly washed. After 
a thorough use of soapsuds, a i per cent, carbolic salve should be 
applied about the anal area. 

In the pruritus secondary to bladder involvement, and so as- 
sociated with frequency of urination, the bladder should be washed 
with boracic solution followed by the injection of several ounces 
of a i per cent, solution of ichthyol, which the patient is to retain 
as long as possible. With more marked involvement of the blad- 
der, the bladder should be washed with boracic solution and then 
anesthetized with an ounce of i per cent, solution of eucain or a 
4 per cent, solution of antipyrin. Four or five ounces of a i : iooo 
nitrate of silver solution should then be injected into the bladder 
and allowed to remain for two minutes. This treatment should 
be carried out twice a week. Internally, urotropin, 5 grains, 
salol, 5 grains, should be taken freely. 

Many cases of pruritus are due to a vaginitis manifested by a 
more or less profuse leukorrhea. A Ferguson speculum should 
be used, for it is the only means of furnishing us with a distinct 
view throughout the length of the vaginal canal. The vagina 
is washed thoroughly with cotton sponges soaked in a 1 per 
cent, solution of lysol. Then there is poured into the speculum 
a 1 per cent, solution of bichlorid of mercury, rendered acid by 
the addition of a few drops of hydrochloric acid, or else pyrolig- 
neous acid or tincture of iodin are poured in. By moving the 
speculum forward slowly, the entire vaginal canal is bathed for 
one minute and then dried by cotton. A long tampon is then in- 
troduced, made and prepared as follows: absorbent cotton is 



PRURITUS VULV.E 21 5 

rolled to a thickness approaching the diameter of the speculum 
and 4 to 5 inches in length. This is covered with a double layer 
of sterilized gauze and fastened at either end by a string tied about 
it, one of the strings left long for the purpose of removing the tam- 
pon. The gauze is dusted thoroughly on all sides with a powder 
composed of i part alum and 4 parts boracic acid, the proportion 
of alum being increased when a more decided desiccation and 
desquamation of the vaginal lining is desired. This tampon is 
introduced through the speculum and kept in place for twenty- 
four hours. In this manner the application is made equally to all 
parts of the vagina, and the secretion is so absorbed that on re- 
moval of the tampon the vagina is found to be dry. When the 
tampon is removed at the end of twenty-four hours a douche of 
one tablespoonful of formalin to the quart of water, twice a day, 
is given. In my experience better results are often gained without 
douches of any sort. Draining the vagina and keeping it dry are 
of decided value. It is often astonishing how rapidly a pruritus 
and a leukorrhea disappear after this treatment. Involvements 
of the cervix and uterus demand the treatment mentioned under 
Leukorrhea. 

Local applications are used for the purpose of healing any 
evident alterations and for the purpose of diminishing the sen- 
sitiveness of the nerve-ends. Watery solutions include 2 to 5 
per cent, carbolic, dilute acetate of lead, 1 to 20 per cent, nitrate 
of silver. Salves include a 10 per cent, calomel ointment; 5 to 
10 per cent, cocain salve (cocain 1 dram, lanolin 1 ounce, olive 
oil 2 drams); or menthol ointment (menthol \ dram, olive oil 
2 drams, lanolin 1 ounce); a carbolic ointment, containing 15 
grains of carbolic acid, to 1 ounce of unguentum zinci oxidi; a 10 
per cent, ointment of anesthesin. 

For pruritus without external alterations: 

1$. Cocain 5 j 

Ol. oliv 5ij 

Lanolin §j 

M. S. — External use. 

1$. Menthol oss 

Ol. oliv 5ij 

Lanolin § j 

M. S. — External use. 

1$. Acidi carbolici gr. xv 

Ung. zinci oxidi § j 

M. S. — For external use. 



2l6 MEDICAL GYNECOLOGY 

Intertrigo demands the following (Unna) : 

1$. Zinci oxidi 3 iiiss 

Sulph. praecip 5iiss 

Mag. silicat 5 j 

Ol. paraffin aib 3iij 

Adip. benzoinat. gij 

M. f. past. 

S. — External use. 

To this 5 per cent, of ichthyol may be added if pustules are present: 

1^. Calc. carb. praecip 5 v 

Zinci oxidi 3 v 

Ol. lini ,. § j 

Aq. calcis § j 

M. f. past. 

S. — External use. 

Simple eczema, characterized by a red, rough, dry epidermis, 
demands the use of zinc oxid ointment, to which may be added 
5 per cent, of ichthyol or 2 per cent, of resorcin. If the eczema is 
of a papulovesicular type (Unna) : 

1^. Resorcin 5 j 

Ichthyol .- 3 j 

Acidi salicylici gr. xx 

Vaselini oiiss 

M. f. unguent. 

S.— External use. 

If the eczema is of a horny, callous nature through scratching 
and mechanical irritation of a simple eczema (as may happen 
on the large labia), or for any itching or pain (Unna) : 

1$. Ammonii sulphoichthyoli (Thigenol) gr. xxx 

Aquas. 3iiss 

Glycerini oiiss 

Dextrini oiiss 

M. f. past. 

Or: 

1$ . Ung. diachylon (Hebra) 5 j 

Vaselini 3ij 

Liantral gr. xv 

Ext. cannabis indie gr. xv 

M. f. unguent. 

S. — External use. 

Because of the eczematous nature of many of the simple cases, 
the following paste is of value. It consists of salicylic acid 15 
grains, amylum 5 drams, oxid of zinc 6 drams and of vaselin 
and lanolin an ounce and a half. 

fy Acidi salicylici gr. xv 

Amyli 3>v 

Zinci oxidi 3 vj 

Lanolini 3 vj 

Petrolati 3 vj 

M. S. — For external use. 



PRURITUS VULV.E 217 

It is in these conditions of intertrigo and eczema that the parts 
should be kept as free as possible of water and cleansing should 
be done with olive oil. If a moist sponge be used first, it should 
be followed by*a cleansing with olive oil. If salves fail, a dusting- 
powder should be used. A good one consists of menthol 15 grains, 
salicylic acid J dram, oxid of zinc 2 drams, amylum and talcum 
5 drams. Stubborn cases demand the aid of a dermatologist, for 
a thorough desquamation of the horny layer must be caused by a 
strong resorcin paste, followed by subsequent treatment of a spe- 
cial nature. 

1$. Menthol gr. xv 

Acidi salicyl 5 ss 

Zinci oxidi 5ij 

Amyli 5 iiss 

Talci 5 iiss 

M. S. — Externally as dusting-powder. 

Attention should be paid to the diet. Autointoxication should 
be prevented; tea, coffee, alcohol, and opium should be prohibited. 
Internally Fowler's solution and the compound syrup of hypo- 
phosphites should be administered. 

John J. Reid advises the use of pilocarpin for its specific effect 
in different forms of pruritus. The ordinary dose is one-quarter 
of a grain, to be given only when the itching manifests itself, and 
not to be repeated until the itching returns. It is well to begin 
with one-eighth of a grain, owing to individual susceptibility. 
The addition of T ^ grain of atropin prevents sweating. The 
pilocarpin is given by mouth. 

In the diabetic form the routine treatment of diabetes should be 
carried out. Codein, aside from its action on the diabetes, dimin- 
ishes the itching. Rudisch has found that the methyl hydrobromid 
of atropin in the total amount of -^ to J of a grain divided during 
the day, with or without codein phosphate i grain or more per 
day, is the best internal medication for diabetes. Douches should 
be taken, twice daily, of a dram of acetate of aluminum to 2 quarts 
of water. The vulva should be washed thoroughly with soap and 
water and then washed well with normal saline solution. It should 
then be thoroughly washed with a 1 : 5000 bichlorid solution and 
carefully dried. With a Ferguson speculum the vagina should be 
bathed with a 1 per cent, nitrate of silver solution. The area of 



2l8 MEDICAL GYNECOLOGY 

the vulva within the external labia should be painted with silver 
nitrate i per cent. Then a bismuth-oxid-of-zinc ointment should 
be applied. The patient should apply this ointment several times 
a day. Office treatment should be carried out twice a week. 

The ointment to be applied contains i dram of bismuth subni- 
trate to an ounce of oxid of zinc ointment. 

Kraurosis. — The vulva should be shaved and thoroughly 
cleansed with soap and water and painted with tincture of iodin 
once a week. Compresses of 5 per cent, creolin should be used. 

Cases not relieved by treatment demand surgical removal of the 
affected area. 



PAIN 
VAGINISMUS 

Vaginismus is a reflex cramp or spastic contraction of the con- 
strictor cunni alone, often also of the levator ani and transversus 
perinei, or of all the muscles of the pelvic floor, which is caused by 
the attempt at or by the actual beginning of coitus and which pre- 
vents coitus. It may be due to unusual sensitiveness of the vulva or 
to actual lesions of the hymen and vulva produced by coitus, and 
which make renewed attempts immediately after marriage pain- 
ful. It is a condition acquired also as the result of infections 
which cause vulvitis or breaks in the tissues and fissures. In some 
cases a very narrow vulva, or, as Sims pointed out, an abnormally 
high or low position of the vulva, is indirectly responsible for vagi- 
nismus. 

In addition to the spastic contraction of the muscles reflexly 
produced from the sensitive or irritated structures of the vulva, 
the same condition is caused by the mental condition and attitude 
of the patient, and is associated with contraction of the adductors 
of the thighs. There is in many of these cases a psychic anxiety, 
especially after previous unsuccessful or painful attempts at coitus. 
Nervousness on the part of the male, and inability to overcome 
the nervousness on the part of the female, with resulting fruitless 
attempts at penetration, plus early emission, increase the nervous 
tendency and result not infrequently in the production of an ac- 
quired neurosis in the female and also in the male. Often this 
condition is of considerable importance. This element is not in- 
frequently noted in nervous, hysterical, hypersensitive, and sexually 
modest women, and, as Veit says, is rarely observed among the 
lower classes. 

Treatment. — Treatment consists in ordering freedom from 
coitus until the patient becomes quieter. The nerves should 
be treated by rest, bromids, and the glycerophosphates of lime and 
soda. Attention should be paid to the treatment of local altera- 

219 



220 MEDICAL GYNECOLOGY 

tions. Examination in these cases is often difficult and must 
sometimes be done under anesthesia. Gentleness in some cases 
and sternness in others generally permits, however, of examination, 
which is essential in determining whether we are dealing with a 
rigid hymen, an unusually sensitive hymen, with visible lesions 
of the vulva, etc., or whether we are dealing with spastic con- 
tractions due to and associated with a state of nervousness and 
psychic anxiety. In some cases it is necessary to excise the hy- 
men. In other cases the method of Sims and Diihrssen is used, 
for the purpose of making two lateral incisions, partially or com- 
pletely separating the constrictor cunni. This is followed by 
gradual dilatation, done with the fingers or with large' glass plugs 
left in place for an hour. This gradual dilatation, using con- 
stantly larger tubular specula, should be done with the preliminary 
use of cocain ointment to avoid pain. Avoidance of pain in the 
treatment of these cases is very important to allay the anxiety and 
fear associated with the thought of any approach to the vulvar 
area. 

DYSPAREUNIA 
Dyspareunia means pain accompanying coitus. This may be 
due to inflammatory conditions in the urethra, the presence of 
urethral caruncles, the existence of an acute or chronic vulvitis. It 
may be due to a vaginitis. More frequently, however, the cause 
is located higher up, and is to be sought in an inflammation or 
infiltration of the connective tissue of the pelvis or an involvement 
of the peritoneally covered organs. A parametritis, either lateral 
or posterior, is not infrequently productive of pain on coitus. The 
most frequent causes, however, are peritoneal adhesions associated 
with a salpingitis or pyosalpinx, with a perioophoritis or with fixed 
retroflexion. It is naturally to be expected that congestion and 
the pressure on the pelvic viscera produced by coitus, and which 
therefore exerts a tugging effect on adhesions, will be productive 
of pain. Dyspareunia in the strict sense is an acquired condition, 
coming on weeks or months after marriage, or after labor or child- 
birth, and in this time element differs, so far as the vulvar causes 
are concerned, from vaginismus. 



PAIN 221 

COCCYGODYNIA 

Coccygodynia implies an alteration in the coccyx or its peri- 
osteal covering, or in the muscles and fascia connected with it, 
as a result of which pain occurs whenever tension or pressure on 
the coccyx or its attached structures takes place. This condition 
may occur as the result of a fall or kick which produces a fracture 
or dislocation of the bone. 

According to Grandin, caries of the bone is a very frequent 
cause. In many cases the condition appears to be due to a local- 
ized rheumatic or gouty condition. In some of the cases the pres- 
sure effects of labor, especially if associated with the use of forceps, 
may have been the cause. In many instances the cause must be 
referred to those inflammatory chronic diseases of the cervix and 
uterus with which a progressive cellulitis is associated. There 
is pain felt on sitting, and on the muscular contraction associated 
with rising from a sitting position or with the pressure exerted 
on defecation. On examination through the vagina or through the 
rectum, pressure on the tip of the coccyx and on the muscles at- 
tached to it produces pain. Pressure exerted on the posterior 
surface of the lower end of the sacrum and the tip of the coccyx 
is productive of pain. The coccyx may be felt in some cases to 
be bent at right angles. In other instances coccygodynia is part of 
a general nervous or neurasthenic state. 

Treatment. — Severe cases, which are sensitive to pressure, as 
a rule, are cured only by subperiosteal resection of the coccyx, 
with or without separation of the muscles attached to the lateral 
periosteal covering of the coccyx. In other less severe instances, 
tonic treatment, antirheumatic treatment, and medication and 
diet looking to the correction of a gouty diathesis are of value. 
Bromids, the coal-tar products, and codein are of aid in relieving 
pain. Hydrotherapy is of value for a general tonic effect. In 
all cases evidencing cervical or uterine discharge, gauze and 
glycerin treatment per vaginam should be used. 

SIGNIFICANCE OF PELVIC PAIN 
The pain from which women may suffer may be acute when it 
occurs for the first time; it may be of repeated acute nature; it 



222 MEDICAL GYNECOLOGY 

may be continuous or steadily progressive, or it may be associated 
only with the menstrual period. 

In the first class we have ectopic gestation, ovarian tumors with 
twisted pedicle, etc., acute inflammatory involvement of the uterus, 
tubes, and peritoneum, and appendicitis. The two latter, when 
acute in their character, are associated with pain, abdominal 
tenderness and rigidity, and other evidences of localized or general 
peritonitis. 

Ectopic Gestation. — The two symptoms of greatest value are 
(a) atypical menstruation, or metrorrhagia, (b) pain. 

The pain of ectopic gestation in the early weeks is an indefinite 
pain, felt on one side or in the pelvis, which later on begins to as- 
sume a colicky nature. This colicky pain is an evidence that 
there is bleeding into the tube or into the peritoneum. 

The colicky sharp pains of ectopic gestation are generally 
closely attended by the appearance of a bloody discharge from the 
vagina. If the colics are very severe, with steady pains between 
them, the abdominal walls may be rigid. The colics in the be- 
ginning of tubal pregnancy are often mistaken for intestinal pains. 
They may not cause the patient to rest more than momentarily 
from her work or pleasure. In other cases the pains are so severe 
and agonizing that a physician is at once sent for, whatever the 
time of day or night. Soreness of the abdomen may pass off in 
an hour or less after a severe ectopic gestation colic, or it may be so 
prolonged as to prevent the patient from walking for a day or two, 
or longer. Occasionally jars of the body in walking, or being 
much upon the feet, cause so much pain that the patient remains 
in bed for a while. In such cases the colics may return after 
shorter or longer intervals. 

If the patient has been accustomed to painful menstruation, 
we should analyze the character of her dysmenorrhea, and ask her 
particularly if the pains which appear in connection with the blood 
at this time are the same as the usual pains of her dysmenorrhea. 
If the patient is intelligent, she will at once say that she never had 
pains like these, and she will at once state wherein the pains and 
the flow of her present attack differ from her previous and painful 
menstruations. If with a diagnosis of miscarriage the patient is 



PAIN 223 

still bleeding and has pains, we should be slow to accept such state- 
ment, unless a fetus has actually been seen by some one. 

The diagnosis is made from the history, from general symptoms, 
from atypical bleeding, by bimanual examination. 

A pregnant tube is always tender when squeezed, and may be 
extremely painful when so treated. Examination per rectum 
discloses an enlarged, painful, sensitive tube. The tube may be 
embedded in blood-clots, or so displaced, or partly or completely 
engulfed in hematocele, that its form and size are indistinguishable. 
Morning sickness and enlargement of the breast, which are the 
ordinary symptoms of intrauterine pregnancy, do not belong to 
the symptomatology of the extrauterine pregnancy. 

Tubal rupture is sometimes associated with a very sharp agoni- 
zing pain, felt in one side and associated with the symptoms of 
internal hemorrhage. Mild or severe attacks of pain when tubal 
abortion or rupture takes place are associated with rapid pulse, 
pallor, attacks of fainting and syncope, absence of temperature or 
subnormal temperature. There is, however, in some cases an 
associated rise of temperature to ioo° or ioi°F., and even as high 
as 103 F., due to the absorption of the fibrin elements of the blood. 
The pain in tubal abortion or tubal rupture is sometimes of a 
diffuse nature, and sometimes is felt so high up in the abdomen as 
to simulate an affection of the gall-bladder. 

The tragic stage of the disease is exemplified by severe colics, 
pallor of the skin, weak and rapid pulse, a fall of temperature one, 
two, or three degrees below normal, rapid breathing, fainting, 
generally vomiting and restlessness, and sometimes a lethargic 
condition from which the patient may be aroused. In this tragic 
stage the pulse may be anywhere from 120 to 180. It may not be 
possible to count it at the wrist, although its flickerings may be 
perceived until shortly before death (Harris). 

Ovarian Cyst. — Ovarian cyst with twisted pedicle is associated 
with a sharp sudden pain on one side or the other which continues 
with evidences of abdominal tenderness and rigidity. The excru- 
ciating colics, the steady pain, the soreness of the abdomen, and the 
fact that it springs from one side of the pelvis, together with the met- 
rorrhagia which so often follows the twisting of a pedicle, afford 
one of the best counterfeits of ectopic gestation. Such cases are,, 



2 24 MEDICAL GYNECOLOGY 

of course, comparatively rare, and are not difficult t6 diagnosticate 
unless the tumor which is twisted on its pedicle was not known to 
exist prior to the colics, and to the atypical menstruation. In 
ovarian cysts with twisted pedicle the last menstruation is not 
usually belated. If the twist is marked, hemorrhage occurs in 
the cyst and in the pedicle, and degeneration of tissue occurs, as- 
sociated at first with localized peritonitis and accompanied with 
such abdominal distention and rigidity of the abdominal wall that 
bimanual examination often makes the diagnosis with difficulty. 
Continuation of this condition may lead to a more general peri- 
tonitis. Adhesion of the ovarian cyst to the surrounding structures 
occurs early. 

Metro-endometritis. — Acute metritis or metro-endometritis, 
not associated with pregnancy or abortion, is usually of gonor- 
rheal origin. Involvement of the endometrium itself causes very 
few symptoms, but involvement of the uterine wall causes a sense 
of weight and fullness in the pelvis. Tenderness is felt in the 
lower abdomen, and there is sensitiveness on moving or jarring, 
with colicky pains due to uterine contractions. Even in the ap- 
parently localized cases there is probably a certain involvement of 
the tubes, and perhaps of the peritoneum. .There is fever and 
rise in the pulse-rate, and examination shows an enlarged sensitive 
uterus, from which is discharged a greenish, thick pus containing 
gonococci. 

The same pain, but slighter, is present in the chronic stage, or 
in subacute cases. Acquired uterine dysmenorrhea often results. 
Occasionally, pelvic pain is experienced between menstrual 
periods, generally in the uterus, but the pain is often referred to 
the umbilical region .or toward the ribs % The uterine pains are 
due to uterine contractions and, when experienced between periods, 
are probably due to retention of secretion with resulting uterine 
stimulation. More frequently than pain, there is noted a sensation 
of pressure in the pelvis, frequent desire for defecation and urina- 
tion, pain in the back and in both legs. These are due to the as- 
sociated pelvic congestion acting on a uterus, ligaments, and con- 
nective tissue made sensitive by inflammation and infiltration. 

Uterine inflammation with associated pelvic inflammation may 
cause severe pain, felt from the crest of the ilium down along the 



PAIN 225 

course of the sciatic nerve. Pain may in some cases be felt in the 
lumbar region and at other times in the region of the pubis. Practi- 
cally the same symptoms are present with the milder forms of 
involvement by the other cocci and bacteria which produce infec- 
tions post partum and after abortion or with intrauterine manifesta- 
tions. 

Pelvic Peritonitis. — When an acute gonorrheal inflammation 
extends into the tubes and involves the peritoneum, and is pro- 
ductive of pyosalpinx and of localized peritonitis, the symptoms 
are those of a severe pelvic peritonitis associated with marked 
pain and tenderness, with abdominal distention, temperature, etc. 
Bimanual examination shows a mass on one or both sides of the 
uterus, but in some cases, with much purulent exudation, the tubes 
and ovaries cannot be made out. Practically the same symptoms 
are present with the pelvic peritoneal involvement produced by 
the other cocci and bacteria which produce infection post partum 
or after abortion or intrauterine manifestation. On the other hand, 
a non-virulent latent gonorrhea may extend gradually through 
the tubes, may involve the peritoneum and produce extensive 
adhesions without acute onset. Its cause may be slow and gradual 
and may affect the patient's general health long before pelvic 
symptoms are annoying enough to attract attention. 

Recurrent attacks of severe pelvic peritoneal pain may be due 
to recurring attacks of appendicitis, but are usually due to re- 
currences or exacerbations of a localized pelvic peritonitis originally 
due to the upward extension of a gonorrheal infection through the 
Fallopian tubes. This is most commonly noted in gonorrheal 
infections of the nature of pyosalpinx. Exertion, lifting, and other 
conditions cause an opening of the tube and the pouring out of 
more pus into the peritoneal cavity. This occurrence is associated 
each time with a new attack of pelvic peritonitis. Wertheim says 
that this recurrence of attacks may be due to the invasion of the 
peritoneum by gonococci which have passed through the tube 
wall. 

Acute Parametritis. — Pain localized in one side or the other 

may be due to a rapid or slow infiltration of one or other of the 

broad ligaments by an acute or subacute cellulitis, either serous, 

serofibrinous, or purulent. Even in the early stages this condi- 

J 5 



226 MEDICAL GYNECOLOGY 

tion can be made out by bimanual examination, when a mass will 
be felt on one side of the uterus, extending gradually over toward 
the pelvis, and in the later stages producing a bulging into the 
fornix and extending upward so that the upper rounded borders 
can be made out through the abdomen above Poupart's ligament. 
An affection of the broad ligament or of the posterior parametrium 
may occur in this acute "fashion after labor, also after abortion, and 
also after operations on the cervix, especially if this cervical opera- 
tion is preceded by forcible dilatation. On the other hand, these 
conditions, especially the involvement of the posterior parametrium, 
may occur as a slow progressive involvement associated with cer- 
vical catarrh, or may come on gradually after labor. 

Salpingo-oophoritis. — Gradually oncoming or progressively 
more intense pain, felt on one side or the other or both, is usually 
due to a slow upward extension of an infection through the Fal- 
lopian tubes, or to the organization of adhesions long subsequent 
to subacute or severe attacks of pelvic peritonitis. This condition 
is a most frequent cause of one or both sided pain in women 
It is extremely frequent in women who are sterile and in uniparae. 
It constitutes a one or both sided salpingo-oophoritis. The tube 
is somewhat swollen, the outer end is closed or covered by ad- 
hesions, the ovary is cystic and covered by adhesions, and the tube 
and ovary are adherent to the posterior wall of the broad ligament. 
It is often noted in women who have been curetted for sterility. 
Its etiology is to be sought in an upward extension of an inflamma- 
tion resulting from the curettage and due to the ordinary septic 
bacteria of mild virulence, or more frequently to the gonococci 
present but unrecognized. Curettage is often done for cervical 
catarrh and for uterine catarrh, and these cases not infrequently 
result in a mild salpingo-oophoritis. After abortion or labor pain 
may come on early, with an acute or subacute infection. If it 
comes on gradually and later, it is due to the upward extension of 
an infection from the uterus. A slow infection of the peritoneum 
is typical of a latent gonorrhea. (See Tubercular Salpingitis.) 

The Relation of Appendicitis to Pelvic Annoyances. — 
There are conditions occurring in the right lower quadrant of 
the female abdomen which at times so simulate each other as to 
symptomatology that, in the early stages especially, a differential 



PAIN 227 

diagnosis is ofttimes difficult. Certain cases of ectopic gestation 
and ovarian cysts with twisted pedicles may render a differential 
diagnosis from appendicitis necessary, but the most frequent 
conditions in which doubt exists are acute, subacute, and chronic 
appendicitis as distinguished from acute, subacute, and chronic 
inflammatory diseases of the adnexa. In so far as the appendix 
and in part the adnexa are covered by the peritoneum, any infec- 
tion of the peritoneum may involve both of these areas. For 
the very same reason the element of physical contact comes into 
play. There are instances of inflammatory involvement of the 
appendix in which this structure is so situated that it becomes 
attached to the uterus, to the tube, or to the ovary. There are, 
on the other hand, conditions involving the tube and ovary, and 
even the uterus, in which adhesion of primarily uninflamed appen- 
dix to these structures results. The element of the situation not 
alone brings these two structures into relation, but makes the 
differential diagnosis at times difficult. 

There are cases of acute gonorrheal involvement 0] the tubes 
with more or less extensive peritonitis in which the differential 
diagnosis from appendicitis must be made. 

Patients are attacked suddenly with pelvic and abdominal pain, 
rise of temperature, etc., and the diagnosis of appendicitis is usually 
made. Vaginal examination plus the examination of the cervico- 
uterine secretion by microscope aids in making the correct diagno- 
sis. In such cases there is a double pyosalpingitis, the omentum 
is often adherent to the uterus or adnexa, and the sigmoid and its 
epiploicae are likewise involved. The outer ends of the tubes are 
generally adherent to the posterior wall of the broad ligament. 
The intestines and peritoneum are not markedly injected. The 
uterus seems large and soft, like the pregnant uterus. 

Now, cases of this acute nature, and especially cases of a sub- 
acute nature, may eventually result in such a situation of the 
adnexa of the right side that only operation can definitely settle 
the original site of the inflammation. 

The uterus may be movable or retroflexed and fixed, and there 
may be unilateral or bilateral pyosalpingitis which is not clearly 
made put. The annoyance is experienced on the right side 
because the ovary and broad ligament of that side are most mark- 



228 MEDICAL GYNECOLOGY 

edly involved and because the ovary is fixed near the pelvic brim. 
Even the sigmoid may be adherent to the right pelvic brim and 
physical examination leads to the diagnosis of chronic appendicitis. 
In such cases the appendix and the mesoappendix are almost 
certain to be involved in the inflammatory adhesions. 

So far as the appendix with its peritoneal covering is concerned, 
it is perfectly natural, as we have seen, to expect that inflammatory 
involvement of the adnexa with which a peritonitis is associated 
may by contact or direct continuity involve the appendix together 
with other intestinal structures in peritoneal adhesions. An 
important question is, Do milder inflammatory diseases of the 
adnexa cause appendicitis? Continuing out from the broad 
ligament along its upper border and extending to the lateral wall 
of the pelvis and running up practically to the base of the appendix, 
is situated the right ligamentum infundibulopelvicum. This 
structure, as well as the broad ligament, is rich in lymphatics, 
and it has been stated that involvement of the adnexa may cause 
an extension of bacteria through these lymphatics up to and 
involving the appendix. While this opinion has been expressed 
by more than one observer, it must be remembered that appen- 
dicitis is an affection which occurs from the lumen of that struc- 
ture, and that bacteria, if they did pass up through these lymph- 
atics, may and do cause infiltration or induration about the cecum 
and the mesoappendix, but could not be responsible for the occur- 
rence of acute or subacute appendicitis. Those men who make 
it a routine practice to remove the appendix in all abdominal 
gynecologic operations are in a position to verify this assertion. 
I have not been able to find a causal relation occurring by this path 
of lymphatic extension. I agree with H. J. Boldt, that inflam- 
matory diseases of the adnexa do not produce inflammatory in- 
volvements of the mucous membrane of the appendix. 

Inflammatory changes of a marked nature may be present in 
the tubes, ovaries, and broad ligaments, and yet the associated 
peritonitis and peritoneal adhesions are slight. In such cases 
the connective tissue of the broad ligaments may be markedly 
involved. Yet with such a chronic alteration in the broad liga- 
ment lymphatics the appendix is found to be normal. Were the 
lymphatic connection with the appendix a ready source of involve- 



PAIN 229 

ment of the latter structure, we should find evidences of this rela- 
tion on operation. 

The question under discussion takes on a quite different phase 
when we consider diseases of the adnexa as possible sequelae of 
appendicitis. Take, for instance, the question of tuberculosis. 
Tuberculosis of the tube and ovary may occur by upward exten- 
sion of tubercle bacilli through the cervix, or tubercle bacilli may 
be deposited through the medium of the circulation, or tubercle 
bacilli may involve the tube and ovary subsequent to their presence 
in the peritoneal cavity. Whatever may be said as to the occur- 
rence of such an infection through the first two channels, it is 
undoubtedly true that in the vast majority of instances tuberculous 
involvement of the appendages occurs subsequent to the presence 
of tubercle bacilli in the peritoneal cavity, with or without micro- 
scopic evidences of tubercular peritonitis. The tubercle bacilli, 
when present in the peritoneal plasma, are carried into the tube 
lumen by the action of ciliated epithelium, and however much or 
little the peritoneal covering may be involved by tuberculosis, 
the lumen of one or both tubes is rarely ever free of tubercles. 
I had the opportunity on one occasion to make microscopic sec- 
tions in a case of tuberculosis of the adnexa in which the appendix 
was removed. The appendix on examination contained tubercles 
and giant cells, and they were not present on the peritoneal surface, 
but were present in the structure and lumen of the tube, so that 
the tuberculous appendicitis was part of the primary condition and 
the tubercular adnexitis was secondary. 

Now, as to the question of appendicitis. When an involvement 
of the appendix takes place and there occurs an associated perito- 
nitis more or less localized or more or less diffuse, we are dealing 
with streptococci or bacterium coli principally, in the peritoneal 
exudation. This exudation need not be great or extensive; it 
need not extend down deep into the pelvis. It may be slight and 
localized immediately around the appendix, yet the action of the 
ciliated epithelium in the tubes attracts toward the adnexa and 
takes up into the tube lumen these infecting bacteria. Here we 
have the possibility of an involvement of the peritoneal covering 
of the tubes, and especially the possibility of an involvement of 
the ovary and its Graafian follicles. 



230 MEDICAL GYNECOLOGY 

I have for a long time noted the occurrence of tubal and particu- 
larly ovarian involvements, generally affecting the right side, 
which occurred in patients in whom an infection from below, except 
of the mildest type, could be almost excluded. In addition, these 
involvements were not at all of a nature which spoke for gonorrhea, 
and the tube was generally open. They developed in individuals 
at a period of life when the lesions cannot be referred to the in- 
fectious diseases of childhood, and the history in many cases pointed 
distinctly to previous mild or more serious involvements of the 
appendix. Thus, I came to the conclusion that the bacteria 
thrown out in the peritoneal exudate resulting from appendicitis 
produced an involvement of the uterine adnexa. This involve- 
ment naturally varies in different individuals, according to the 
susceptibility of the peritoneum to inflammation and to adhesions, 
according to the virulence of the bacteria, and the resistance of the 
patient and other factors which we are at present unable to dis- 
tinctly determine. 

It might be expected that evidences would be present in the 
genito-urinary tract which would definitely settle for us, in all 
cases, the point from which the infection started ; but we all know 
that, especially in subacute and chronic cases, evidences in the 
cervix and uterus may be almost wanting and the point of origin 
of the infection is therefore doubtful. The history of previous 
attacks does not always give a definite picture pointing clearly 
either to appendicitis or to infection of the adnexa from below. 
Marked appendicitis may cause such a pelvic peritonitis as to 
involve both tubes and ovaries very markedly. Omentum may 
be adherent to uterus and adnexa. Both tubes and ovaries are 
bound down by thin cobweb adhesions. Both ovaries are cystic, 
and the right one especially may contain one very large single 
cyst. The right side is more involved in structure and by adhe- 
sions than is the left. In such cases the appendix is of course 
very markedly involved, and in one of my cases was spontaneously 
amputated from the cecum and connected with it by adhesions 
only. 

Primary involvement of the appendix of a slight degree may 
affect especially the right adnexa. The associated peritonitis 
produces a pelvic peritonitis; the right tube is often closed and 



PAIN 231 

adherent, and the right ovary is enlarged and cystic and often 
contains one large Graafian follicle cyst. 

(1) Appendicitis in the form of an inflammation of the mucous 
membrane does not result from inflammatory diseases originating 
in the uterus or adnexa. (2) Involvement of the appendix viewed 
as a peritoneally covered organ may take place as part of a peri- 
tonitis more or less localized, or more or less extensive, which has 
its origin in inflammatory diseases of the adnexa. (3) Severe inflam- 
mations of the appendix, in so far as they cause a pelvic peritonitis, 
or in so far as the accumulation of pus is located in the pelvis, 
naturally involve the uterus and adnexa in adhesions, do not cause 
pyosalpinx, but may cause tubo-ovarian cysts. (4) A differential 
diagnosis as to original site of the infection is often impossible, 
except from the operative clinical standpoint, and even then is 
not always certain. (5) Mild attacks of appendicitis without 
the production of well-defined peritonitis may involve the adnexa 
without adhesions, but especially by infection of the Graafian 
follicles, alterations of the ovarian stroma, and the production of 
varicocele of the broad ligament. 

Varicocele. — There is often noted in one or other of the broad 
ligaments a tremendous dilatation of the veins in the upper part 
of the broad ligament and near the hilus of the ovary. This con- 
dition is like that in the male known as varicocele. It is quite 
certain that many cases of unilateral or bilateral pain often diag- 
nosed as salpingo-oophoritis show on operation this alteration in 
the upper border of the broad ligament. By many this is con- 
sidered to be the result of the displacement of the uterus and in- 
terference with the circulation of blood to and from the uterus. 
It cannot be denied that this condition is often found in retro- 
flexion; however, it is by no means infrequent where the uterus 
is normally placed. While it cannot be denied that circulatory 
causes may be responsible, yet I have found the condition so often 
combined with pathologic changes in the tubes and ovaries that 
it constitutes in many instances a para- oophoritis, that is, a para- 
metritis involving the upper part of the broad ligament, and more 
particularly the area situated near the ovary, and also the ligamen- 
tum infundibulopelvicum. While the cause of this condition is 
most frequently an infection extending from the cervix or uterus 



232 ' MEDICAL GYNECOLOGY 

after labor, abortion, or curettage, yet a primary involvement of 
the peritoneum may also be the cause. 

Oophoritis. — Pain in the right or left side or both sides, but 
especially on the right side, is frequently due to a structural in- 
volvement of the ovarian tissue without the presence of adhesions 
or closure of the tubes. With this is very frequently associated a 
varicose condition of one or both broad ligaments or a shortening 
of one or both ligamenta infundibulopelvica. This condition of 
varicose veins of the broad ligament may be due to thrombotic 
or other changes subsequent to curettage, or to mild and often 
unrecognized infections extending into the parametrium from cer- 
vix or uterus, especially after labor or abortion. These may be 
responsible, through circulatory and interstitial disturbances, for 
changes in the structure of the ovary and for the production of 
small cystic degeneration, or cirrhosis. It is certain that appendi- 
citis, too, may cause such a change in the broad ligament and may 
produce inflammatory changes in the ovary. These are often 
found on the right side combined with the special symptomatology 
of ovarian involvement and with a shortened ligamentum infundi- 
bulopelvicum. This pathologic involvement of the ovary and 
broad ligament of the right side is often noted at operation to be 
associated with involvement of the appendix and the mesoappendix. 

As a result of any of the above causes the ovary may be altered 
in size and contain cysts. The tunica albuginea may be thickened 
and the stroma may be indurated, so that the term "cirrhotic 
ovary" seems justified occasionally. The characteristics oj this 
ovarian involvement are not modi-lied greatly by the symptoms 
oj the involvement oj the appendix. So far as the ovary is con- 
cerned, there is a steady, gnawing, burning pain, which often 
radiates into the thigh or extends upward toward the ribs or which 
may be felt in the iliac bone. The pain is more noticeable after 
walking or on exertion, and is therefore most marked at night. 
During the week preceding menstruation it increases in intensity, 
and on the establishment of menstruation it may grow less or it 
may continue. An associated annoyance is nausea, which may 
be felt before, during, or after menstruation, and which is some- 
times very marked. The pain felt in the ovarian region may at 
some menstrual periods be marked, at other periods less severe. 



PAIN 233 

The reason for these symptoms can be readily understood. We 
are dealing with an ovary, altered in structure, and with a varicose 
broad ligament. Menstrual congestion produces hyperemia in 
these structures, and pain is therefore increased during the pre- 
menstrual period. If a follicle ripens in the involved ovary, the 
pain is more severe. If the tunica is thickened, the rupture of the 
follicle is prevented and the follicle increases in size. Rupture 
of the follicle eases the pain. Bimanual examination at an inter- 
menstrual period may show nothing palpably except a sensitive 
ovary. It may, if frequently repeated, show the period of greatest 
pain to be associated with the presence of an enlarged ovary and 
an unruptured follicle. Women with these alterations may suffer for 
months and years with this almost constant but not always severe 
pain, which eventually has a harmful and injurious effect on their 
physical and nervous state. Even though this ovarian pain is most 
frequent in women with an asthenic nervous system, and even 
though the pain is caused by the functional congestion of men- 
struation and by ovulation, nevertheless it is this function, carried 
out in an ovary altered even though slightly as to its stroma and 
tunica, which causes the local annoyance. Often enough there 
is associated a uterine displacement or enteroptosis or ren mobilis 
which is considered the cause of the pelvic annoyance. When 
these patients are finally reduced to a state of nervous and physical 
asthenia, the diagnosis varies from appendicitis, movable kidney, 
nephrolithiasis, to neurasthenia and hysteria. A close study of 
the history of the case, of its development, and of its course, shows 
the annoying symptoms to be related to the functional activity 
of the ovary. Sometimes these cases are correctly classed under 
ovarian dysmenorrhea. More often the appendix is removed 
through a small incision, or an Alexander Adams operation is 
done, or a movable kidney is fixed, and, naturally enough, the 
symptoms continue. It is certain that a neurasthenic predisposi- 
tion renders patients more sensitive to pain, and that alterations 
in the ovary need not be marked to produce the symptoms men- 
tioned above. On the other hand, the long duration of pain is 
sure to increase the neurasthenic predisposition and may bring 
on a state of semi-invalidism. 
The differential diagnosis between such a chronic oophor- 



234 MEDICAL GYNECOLOGY 

itis and salpingo- oophoritis cannot always be made. There is 
a disease of the ovary, called ovarian neuralgia, in which the 
pain comes on suddenly, lasts for a few hours or a day, and 
ceases suddenly at the menstrual period. This is considered by 
some to be an ovarian neuralgia, while by others it is considered 
to be simply the result of an oophoritis of the form just 
described. 

Right-sided Pain. — Prolonged right-sided pain from which 
women suffer is not always easy to diagnose. In fact, the dif- 
ferential diagnosis between an involvement of the appendix and 
involvement of the ovary is often extremely difficult. We are 
very frequently concerned with those cases where both conditions 
are present. If a previous severe, sharp attack of appendicitis has 
produced peritoneal involvement around the tube and ovary of 
the right side, these structures are bound down by adhesions, 
but pus is not found in the tubes. It is not necessary that the 
appendix be attached close to the tube and ovary, but usually in 
these cases there are thin adhesions around the appendix or the 
appendix is attached behind the cecum. The meso-appendix 
is shrunken. Bimanual examination divulges a sensitive ad- 
herent tube and ovary, and only the history in many cases permits 
of the diagnosis of a causal appendicitis. 

Pregnancy. — In pregnancy pain is a frequent symptom, local- 
ized in one side or the other, and due perhaps to some inflam- 
matory involvement of the tube and ovary. On the other hand, 
there are pains that are localized in the uterus, in which the fault 
is probably to be sought in an inflammatory involvement of the 
endometrium. In pregnancy, too, a pyelitis must be excluded. 
This condition is not so very infrequent. 

The pain in abortion in many cases is a sense of fullness and 
weight in the pelvis like that associated with menstruation, but 
more intense. The pains of labor are simulated, however, in some 
cases when the uterus contracts actively and the cervix dilates. In 
the expulsion of the ovum in whole or in part, or when large pieces 
or clots are being expelled, there is, of course, the associated bleed- 
ings, which with a history and bimanual examination make the 
diagnosis. 

Backache. — The most frequent causes of continued backache 



PAIN 235 

are pelvic congestion and parametritis posterior. The latter repre- 
sents an involvement of the lymphatics of the uterosacral liga- 
ments or the posterior parametrium by a previous cervical infec- 
tion or by a chronic cervical catarrh. Infiltration of lymphatic 
connective tissue around the rectum is an added cause. The 
presence of rectal ulcerations is to be excluded. Involvement of the 
coccyx is another factor. It is important in backache to see if bi- 
manual examination or manipulation will produce this pain or 
the sensation of stretching and discomfort in the rectum of which 
the patient complains. The simplest manipulation is to insert 
the fingers into the posterior fornix and lift the cervix up toward 
the symphysis. This manipulation puts the uterosacral liga- 
ments and posterior parametrium on the stretch, and if it is pro- 
ductive of the same pain as that of which the patient complains, 
the diagnosis is made. A large subinvoluted uterus associated with 
pelvic congestion is often productive of backache, but, as a rule, 
those cases which produce the greatest annoyance are those in which 
there has been chronic inflammation of the cervix or uterus, with 
deep laceration of the cervix and with chronic involvement of the 
cellular connective tissue. In many patients backache depends 
upon rheumatic or gouty diathesis. 

Gastro-enteroptosis associated with movable kidney and often 
with hysteroptosis is responsible for the indefinite, irregular, and 
changeable position of the pain felt by many women. This splanch- 
noptosis is often present in women who have borne several 
children. There is an inelasticity of the general elastic structures 
of the body and of the abdominal wall. Errors of digestion and 
general nervous symptoms are present. The pelvic congestion asso- 
ciated with the enteroptosis, and particularly the hysteroptosis, 
produces a sensation of weakness in the back, a sensation of drag- 
ging, and in some cases a steady dull feeling described as a pain. 
In this connection it must be stated that retroversion and retro- 
flexion are considered to be often a cause of backache and of pelvic 
discomfort. This is due to the hysteroptosis. I am of the opinion 
that the very vast majority of cases of retroversion and retroflexion 
with which pain is associated are really due to inflammatory 
conditions in the uterus, but are more particularly due to pelvic 
parametritis and to unrecognized ovarian involvement. Salpingo- 



236 MEDICAL GYNECOLOGY 

oophoritis is in many cases a lesion which cannot be readily made 
out by bimanual examination, and when associated with retrover- 
sion or retroflexion this displacement of the uterus is often con- 
sidered to be the cause of the annoyances. 

Pain felt at a regular menstrual period, and developing at the 
time that menstruation began or later, is known as dysmenorrhea. 
Dysmenorrhea, when acquired, is usually of an inflammatory nature. 
It may be due to processes occurring in the uterus near the internal 
os, or in the lining or wall of the uterus, or in the tubes or peri- 
toneum or ovary. When such infiltrated, inflamed tissues are 
stretched by the congestion of menstruation, sensitiveness and 
pain are naturally excited. 



TREATMENT OF PELVIC PAIN 

In acute inflammatory stages we make use of absolute rest in 
bed, cold applications to the abdomen, or the cold coil. When 
peritoneal irritation is present, the ice-bag should be used, but 
the patient should not be annoyed by its weight. The bowels 
should be regulated. With high continuous fever sponge-baths 
or cold rectal irrigations should be used. Vaginal cleansing 
douches are of value to remove abundant secretion, and should 
be given at a temperature of 70 to 8o° F., but with low pressure. 

The vast majority of the cases can be carried through the acute 
stages by conservative treatment. If conservative treatment is 
carried out for a fair period of time without improvement, it is no 
longer indicated. When high fever and marked peritoneal ir- 
ritation complicate a pus sac with thin wall or an abscess of the 
ovary, operation is necessary. If observation of the temperature, 
careful repeated bimanual examination, and a leukocyte count 
show continuation of high temperature, the finding of a constantly 
growing pus focus, the continuation of a leukocytosis over 15,000, 
and the existence of peritoneal irritation and pain, we are concerned 
with a purulent accumulation, which demands vaginal incision and 
drainage. 

If, however, on the use of conservative treatment fever ceases 
and pain diminishes, cold applications are substituted by stimu- 
lating applications to the abdomen, and subsequently by the ad- 



PAIN 237 

ministration of long sitz-baths of 95 F. Any return of temperature 
demands the treatment applicable in the acute stage. 

Remarkable benefit and improvement are obtained by rest in 
bed for long periods of time. The associated congestion and 
edema of the broad ligaments diminish, and eventually there 
results a marked resorption of the inflammatory exudate, leaving 
the adnexa in such a state that if operation is necessary, we are 
dealing mainly with adhesions of the peritoneum, with alterations 
in the tubes and ovaries, but with relatively normal ligaments as 
regards infiltration. If the condition results in pyosalpinx, con- 
servative treatment carried over a long period of time, supple- 
mented by the use of warm abdominal applications, produces a 
thickening of the pus and often furnishes a pus sac whose contents 
are sterile. I have treated many cases by this conservative method, 
and, especially in such as have occurred after labor or abortion, 
and subsequent operation, when necessary because of pain, has 
shown a surprisingly slight purulent involvement of the tubes 
and peritoneum in many cases. 

In the treatment of very chronic adnexal diseases much heat should 
not be used so long as fever continues. Later, stimulating ab- 
dominal applications should be made, warm douches with small 
amounts of water should be given, and warm sitz-baths of ten 
minutes' duration may be taken. If fever has not recurred and 
no pus sacs are present, long, profuse, hot vaginal douches and 
warm abdominal compresses should be used. Warm prolonged 
sitz-baths and full baths are of value. 

In chronic cases without fever, where pus accumulations are 
absent, this treatment should be supplemented by regular thorough 
packing of the vault of the vagina with gauze. This method, 
plus massage, may cause pain to disappear and menstruation to 
become regular. This is brought about through the increased 
blood-supply furnished to the uterus and tubes, as a result of 
which the inflammatory products may be absorbed and pregnancy 
may take place. The use of the Nauheim baths and of sitz- 
baths is of value in the chronic stage and recurrence of attacks is 
often avoided. In many cases, especially the gonorrheal form, 
very slow improvement takes place, for the original condition 



238 MEDICAL GYNECOLOGY 

remains unchanged, through either the virulence of the gonococci 
or the susceptibility of the patient. 

The same methods of after-treatment apply to those cases which 
have been incised vaginally. 

The treatment of the cervical conditions is given in the section 
on Cervical Catarrh or Endocervicitis, and implies the use of vaginal 
pressure therapy and the use of appropriate douches, sitz-baths, 
and abdominal applications. 

Subacute or chronic inflammations not associated with pus 
constitute a goodly portion of the cases coming for ambula- 
tory treatment. It is necessary to take into consideration the 
associated vulvitis, vaginitis, cervicitis, parametritis, and endome- 
tritis, if any or all of these be present. It is in those cases 
in which there has been peritoneal involvement that I personally 
consider intrauterine therapy harmful. Hence treatment is 
limited to what can be accomplished through the vagina. The 
vagina is, of course, at each treatment thoroughly cleaned. Ero- 
sions, if present, are treated by carbolic acid and iodin, and later 
on by silver nitrate, as mentioned in the section on Cervical Ca- 
tarrh. The vault of the vagina should be thoroughly painted 
two or three times a week with tincture of iodin. Boroglycerin 
or ichthyol-glycerin should be poured into the speculum and the 
posterior fornix and the upper part of the vagina should be gently 
but thoroughly packed with gauze. We accomplish thereby pres- 
sure of a gentle sort, a mild stretching of adhesions, and favorable 
alterations in the pelvic congestion, added to which is the influence 
of dehydration on the uterus and cervix. After such vaginal pack- 
ings the patient should go home and go through no exertion. 

On removing the vaginal packing after twenty-four hours the 
patient should take a hot vaginal douche, after which she should 
lie down for a period of one hour. During the menstrual periods 
patients should be extremely quiet, for during this time recru- 
descences of inflammatory processes may occur. In the course 
of time it is possible to relieve many of these patients of their an- 
noyances, and prolonged hot vaginal douches, followed by mas- 
sage by the bimanual method, may bring a fixed uterus back into 
normal position, so that in some instances a pessary may be worn 
with comfort. The degree of annoyance does not depend on the 



PAIN 239 

amount of infiltration or the extent of adhesions, but rather on the 
individual sensitiveness of the patient. In some cases slight changes 
cause marked pain, while in others marked alterations cause 
relatively little annoyance. 

In many cases the Nauheim baths have a remarkable resorp- 
tive influence on pelvic inflammations in the afebrile period 
and a very beneficial effect on congestions and those infiltrations 
in the pelvic cellular connective tissues which are productive of 
so much pain and backache. 

Retroflexions and versions, especially if associated with descent 
of the uterus, with non-elastic ligaments and pelvic congestion, 
demand preliminary treatment by intravaginal pressure therapy, 
followed by the introduction of an appropriate pessary. The 
support given to the pelvic organs often quickly relieves the sense 
of weight and backache. (See p. 93.) Splanchnoptosis and 
loose abdominal walls are relieved by appropriate abdominal 
supports or by the use of Rose's bandage. (See pp. 108, 109.) 
Constipation must be overcome and permanently cured by hydro- 
therapy, massage, exercises, proper food, etc. (See Constipation.) 

Backache may be due to hysteroptosis not accompanied by a 
retrodeviation. Here we often note marked pelvic congestion. 
The use of a pessary to hold the cervix high up and far back, the 
use of an abdominal support, the use of the sinusoidal current 
(see Constipation) are often of very decided benefit. 

Pain may be temporarily relieved by the same drugs as are used 
for the relief of dysmenorrhea. (See p. 165.) The value of abdo- 
minal applications, of douches, of sitz-baths, of counter-irritation, 
and of electricity for the relief of ovarian pain can be noted by a 
reference to the sections which deal with these therapeutic pro- 
cedures. 

In many cases no form of treatment removes the pain, which, 
if long continued, produces sleeplessness, loss of weight, digestive 
disturbances, and a profound condition of loss of nervous tone and 
neurasthenia. Only operation brings relief. Aside from condi- 
tions associated with adhesions, it is the ovary, and its surrounding 
area of broad ligament, including the ligamentum infundibulo- 
pelvicum, which is responsible for the greatest misery. Lesions 
which often escape distinct bimanual determination may cause 



240 MEDICAL GYNECOLOGY 

more suffering than gross palpable involvements. We should 
guard ourselves against the danger of minimizing the degree of 
suffering complained of and against the danger of attributing 
pain to hysteria, neurasthenia, and imagination. We should also 
refuse to surgically correct displacements for the relief of pain 
which resists the various forms of treatment without making 
an exploratory laparotomy. Hence when such uterine displace- 
ments are present, an intraperitoneal operation should always 
be selected. No more grateful patients can be found than those 
relieved of pain by non-operative methods. Pain is the indication 
which calls for operative interference when other methods fail. 
Conservative operations, operations which preserve part of an 
ovary or part of a tube, when pain is due to these structures and 
their involvements, are poor surgery. In the vast majority of cases 
operated on because of pain, preservation of menstruation or at- 
tempts to conserve the tubes for the purposes of fecundation are 
of secondary import and should not interfere with the radical 
cure of the primary indication. In right-sided pain particularly 
we should not be content with removal of the appendix, but should 
remove the right adnexa entirely if the symptomatology points 
to tubal or ovarian involvement, as is the case in the vast majority 
of women in whom appendicitis is diagnosed as the cause of the 
steady, continued pelvic pain in the right side, increased during 
menstruation. The macroscopic appearance of the tubes and 
ovaries is no sure guide as to the degree of pain subjectively felt 
by the patient. If we paid less attention to the operative correction 
of versions and flexions, if we paid less attention to the supposed 
need for curettage and to the repair of lacerated cervices and 
perinea for the correction of pelvic pain, and directed our medi- 
cal and surgical attention to the cellular connective tissue, to the 
peritoneum, to the tubes and ovaries, we should be doing our 
patients greater justice. 



STERILITY 

After the menstrual function is established, ripe ova are sup- 
posedly given off at regular intervals from the surface of the ovary. 
As a Graafian follicle gradually approaches the surface of the 
ovary, the peripheral area becomes continually thinner, until 
finally the tension produced by the liquor folliculi causes bursting 
of the follicle, and the ovum leaves its bed and is thrown out into 
the peritoneal cavity. Here it lies in the peritoneal plasma, 
awaiting entrance into one or other of the Fallopian tubes. The 
Fallopian tubes are lined with ciliated epithelium and the outer 
end of each Fallopian tube is large and lined with folds, which 
makes the area covered by ciliated epithelium quite extensive. 
The cilia produce a current which draws the ovum in the peritoneal 
plasma into the tube. The current created by the ciliated epithe- 
lium of either tube is so marked that if one tube is absent or closed, 
or if the cilia do not functionate, an ovum from an ovary of the 
affected side may be drawn up into the opposite tube, the cilia of 
which create a current sufficient to direct and draw the ovum 
into the tubal lumen, and to carry the ovum on into the uterus. 

When active spermatozoa are deposited in the vagina, they pass 
up by their own efforts, through the cervix and through the uterus, 
against the current produced by the ciliated epithelium which 
lines the endometrium, out through the tube against the current 
created by the ciliated epithelium. The usual meeting-place for 
spermatozoa and ovum is at the outer end of the tube, though this 
meeting may take place even within the peritoneal cavity, or 
probably, too, in the uterus. 

Fecundation and pregnancy imply the union of healthy active 
spermatozoa with a ripe healthy ovum and the passage of this 
ovum through the tube. Sterility may be due to the absence of 
one or both of these essential primary factors or to obstacles which 
prevent their union or to obstruction to the passage of the fecun- 
dated ovum through the tube. 

16 241 



242 MEDICAL GYNECOLOGY 

CAUSES 

Amenorrhea. — Primary amenorrhea may mean absence of 
genitalia or an underdevelopment of uterus or ovaries. Such a 
hypoplasia may be primarily uterine or may be secondarily pro- 
duced by failure of development or of function on the part of the 
ovaries. 

Amenorrhea may be due to adhesion of hymen or to atresia of 
the vagina or cervix. It is also associated with and due to obesity, 
in which case the amenorrhea is either absolute or relative. 

Secondary amenorrhea may be temporary or permanent. It 
depends on blood states, on atrophy of the ovaries as a result of 
infectious diseases, diabetes, and the abuse of opium; it may be 
due to diseases of the ductless glands; it is often associated with 
increasing obesity. Amenorrhea often exists simply as a pre- 
cocious menopause, or is due to lactation atrophy or to atrophy 
of the uterus produced by too energetic use of the curet or of 
atmocausis. Amenorrhea of itself, however, does not necessarily 
preclude the possibility of pregnancy taking place. Ovulation 
may take place without menstruation, but menstruation does not 
take place without ovulation. 

Spermatozoa. — When normally developed genitalia are pres- 
ent in the female, the cause of sterility cannot be properly diag- 
nosed without first determining the existence and presence of 
active, healthy spermatozoa. Therefore the examination of the 
seminal secretion is essential. It may be found that no sper- 
matozoa are present, or inactive spermatozoa may be found, or 
else they may be present in proper number and in a proper state 
of activity. Examination of the prostatic seminal secretion is 
further valuable, for with any of the above states of the spermatic 
fluid proof of an old inflammatory process in the male genitalia, 
in the shape of pus cells, bacteria, and cocci, may furnish evidence 
of the cause of sterility. If pus cells are present and at the same 
time normal spermatozoa are found, we must often look to the 
pus cells as explaining the. cause of sterility, through the inflam- 
matory processes which may have been set up in the female genital 
tract. Granted, then, that normal spermatozoa are present, the 



STERILITY 243 

next point is to determine the existence of normal ova, unless gross 
pathologic lesions closing both tubes are found. 

Ova. — In a woman who menstruates normally and in whom 
the uterus and tubes and ovaries seem properly developed, it must 
be taken for granted that ripe ova are given off at regular intervals. 
There are cases of properly developed ovaries which produce a 
normal congestion, but associated therewith is an underdeveloped 
small uterus. There are other cases with normally developed 
uterus in which the ovaries are small and fail to produce a normal 
congestion. In obese patients there is often found a small uterus 
and the menstrual process is such that insufficient ovarian action 
must be taken for granted. Such patients are either primarily 
obese, and have evidenced this condition of the uterus and ovaries 
from adolescence, while in other patients the obesity and the as- 
sociated atrophic uterus and diminished ovarian activity are ac- 
quired at a subsequent period. There are cases in which Graafian 
follicles develop, but never to the full extent. Often they do not 
rupture, but form the so-called atresic follicles. In such conditions 
we are apt to find various degrees of actual or relative amenorrhea 
and various degrees of hypoplasia, under- development, or atrophy 
of the uterus. It is of importance to determine this fact. 

Hypoplasia. — Hypoplasia of the uterus is a frequent cause of 
sterility. The blame does not rest upon the ovaries if menstrua- 
tion is of normal duration and the congestion from the ovaries is 
of normal degree. If we are dealing with a uterus concentrically 
or excentrically smaller than normal and the molimina are slight 
or irregular, this implies in some instances the absence of ripe ova 
or the existence of tubes which cannot carry the ovum into the uterus, 
and generally the existence of a uterus which, as regards its size, 
the character of the endometrium, and the failure on its part of 
periodic development to a normal decidua, does not favor the en- 
trance of an ovum into the uterus, or its embedding if it does enter 
the uterus. 

Obstruction to Progress of Spermatozoa. — If normal sper- 
matozoa are found to be present, and if the uterus is of normal size 
and normal tubes and ovaries are palpated, and if menstruation 
follows a normal course, sterility is due either to failure of the sper- 
matozoa to unite with the ovum or to inability on the part of the 



244 MEDICAL GYNECOLOGY 

ovum when fecundated to be drawn into the uterine cavity. Fail- 
ure of the spermatozoa to unite with the ovum implies an obstruc- 
tion or obstacle somewhere between the vagina and the outer end 
of the Fallopian tube. There are cases in which the character of 
the vaginal secretion is such that the spermatozoa are injured and 
their activity is destroyed. Such instances, while not frequent, 
are nevertheless considered possible. 

Cervix. — The cervix supposedly furnishes a frequent point of 
obstruction to the upward movement of the male element. Sten- 
osis of the external os, a long narrow cervix, stenosis of the internal 
os, or a profuse normal or a profuse pathologic cervical secretion 
are considered the elements which impede the upward movement 
of the spermatic cells. However, in innumerable women with 
extremely narrow or pin-hole external os pregnancy takes place. 

There is more reason, however, to attribute to the internal os a 
position of importance in the etiology of sterility. Here we are 
dealing not infrequently with a congenital or acquired actual 
stenosis or relative stenosis due to overgrowth of the cervico- 
uterine lining. It may be possible for a sound to readily enter the 
uterine cavity, and yet so excessive may be the amount of over- 
growth of the mucous membrane that an obstacle to the moving 
spermatozoa actually exists. There are cases where the normal 
mucous secretion of the cervix is remarkably excessive, and yet 
the spermatozoa pass upward. If, however, the cervical secretion 
is pathologic as the result of an inflammation or catarrh, there is 
perhaps more reason to consider its irritating presence as a factor 
in the production of sterility through injury to the spermatozoa. 
These conditions existing in the cervix, together with the condition 
of acute anteflexion with production of obstruction at the internal 
os, are generally considered as extremely important factors in the 
etiology of sterility. Some of these cases do finally become preg- 
nant after the cure of the hypersecretion or the cervical catarrh, 
after dilatation of the cervix, after curettage of the overgrown 
cervico-uterine mucous membrane, after surgical treatment of the 
anteflexion, etc., yet the number of cases of sterility cured by these 
procedures is relatively small and the cervix must not be considered 
as an all-important factor. 

Endometrium. — On the other hand, an endometrium which 



STERILITY 245 

has been the seat of chronic inflammation may become so atrophic 
and its decidual reaction may be so altered as to not admit of 
embedding on the part of the fecundated ovum. If we are con- 
cerned with a hypertrophic overgrown endometrium, we mav find 
in this condition an explanation for certain cases of sterility, be- 
cause the changes which go on in the embedding of the ovum are 
such that the ovum is cast off very shortly after it has found its 
nest. This etiology, however, is more frequently productive of 
early abortions than of absolute sterility. There are cases per- 
haps in which the hypertrophic endometrium may obstruct the 
openings of the tubes into the uterine cavity, but this occurrence 
is not a frequent one. 

The endometrium has a bearing on the production of sterility. 
If we are concerned with inflammatory endometritis associated 
with profuse acrid discharge, it is possible that this sweeps out the 
on-coming spermatozoa, prevents them from coming into union 
with the ovum, or destroys their activity. It is possible that 
fibroids of the uterus may so alter the shape of the uterine cavity 
as to form a mechanical obstruction to the spermatozoa. If so, 
they must be very large. The number of instances in which preg- 
nancy occurs in the presence of fibromata shows that this obstruc- 
tion, to be effectual, must be mechanically absolute. Fibroids, 
if associated with menorrhagia or metrorrhagia, sweep out the 
spermatozoa as they ascend, or sweep out the ovum as it enters 
the uterine cavity, or furnish an endometrium which is not well 
adapted to the embedding of an ovum. 

Tubes. — Any inflammation in the tubes, so long as it does not 
produce adhesion of the mucosa or does not form a mechanical 
obstruction by adhesions or by the presence of much purulent ac- 
cumulation, is not necessarily an obstacle to the movement of 
the spermatozoa, for they pass out to the abdominal end by their 
own movements against the current created by the ciliated epithe- 
lium when present. A very frequent cause for failure of union 
between the ovum and spermatozoa, however, is the closing of 
the outer end of the Fallopian tubes by peritoneal adhesions. In 
this event the spermatozoa cannot pass out into the peritoneal 
cavity and the ovum cannot enter into the Fallopian tube. In 
some cases peritubal inflammation causes twists, bends, and 
constrictions of the tubal lumen. 



246 MEDICAL GYNECOLOGY 

Ovary. — There are cases in which the ovaries are embedded 
in adhesions or surrounded by mild cobweb adhesions so that a 
Graafian follicle which bursts is unable to send its ovum into the 
peritoneal cavity. This, of course, is an absolute cause of sterility. 
In other cases the exit of the ovum from the ovary is not prevented, 
but adhesions at the abdominal end of the tubes prevent the 
spermatozoa from uniting with the ovum and prevent the 
ovum from being attracted into the Fallopian tube. 

Obstruction to Progress of Ovum by Salpingitis. — Perhaps 
the most frequent cause of sterility is a mild salpingitis. The 
ovum and the spermatozoa are able to unite within the peritoneal 
cavity, but the fecundated ovum cannot enter the uterus. In 
these cases there are no adhesions around the abdominal ends of 
the tubes, but the tubes are the seat of a salpingitis of varying 
degrees. With a salpingitis of even mild character, and especially 
so if there is a catarrhal salpingitis, the ciliated epithelium of the 
Fallopian tubes may not functionate. Without action on the part 
of the ciliated epithelium a fecundated ovum can enter neither 
the tube nor the uterus. This is an extremely frequent cause of 
sterility, and in some instances can be corrected or cured when, in 
the course of time, the salpingitis is healed and the ciliated epithe- 
lium is restored to the normal. Strange to say, in the early stages 
of gonorrheal salpingitis with purulent accumulation pregnancy 
may take place in the uterus in some instances and in other cases 
in the tubes. 

Congenital Causes. — The causes of sterility in the female are 
either congenital or acquired. The congenital cases are those in 
which we are concerned with ovaries which do not produce ripe 
ova, with tubes which are under-developed and which do not trans- 
mit the ovum, or with a uterus which is hypoplastic and does not 
furnish a proper nest for the embedding of the ovum, or with a 
cervix stenosed at the internal os, with a very acute anteflexion 
of the fundus, or with a congenitally narrow cervix. 

Acquired Causes. — The acquired causes of sterility in the fe- 
male are in the vast majority of instances due to inflammation. 
The diseases of childhood may produce necrotic or hemorrhagic 
involvement of the cervix, uterus, tubes or ovaries. This may 
result in stenosis of the cervix or in hypoplasia of the uterus or in 



STERILITY 247 

hypoplasia of the tubes or in hypoplastic ovaries. The other 
inflammatory causes are infections by the ordinary inflam- 
matory bacteria or by the gonococcus. These infections may 
produce an acrid discharge in the vagina and cervix or a hyper- 
secretion of a pathologic character. They may produce a profuse 
discharge from the uterus, or they may so alter the lining of the 
uterus as to prevent a normal decidual reaction, but the most fre- 
quent seat of location of the acquired inflammatory cause of sterility 
is to be sought in the Fallopian tubes. The resulting salpingitis, 
even with the milder forms, simply destroys the activity of the cili- 
ated epithelium. In the more severe forms there is a pyosalpin- 
gitis or closure of the abdominal ends of the tubes by peritoneal 
adhesions, or the ovaries are enveloped in peritoneal adhesions 
which prevent the exit of ova, provided that the ovaries still re- 
tain their function of normal ovulation. Those causes which pro- 
duce salpingitis almost surely produce temporary or permanent 
sterility. There are two forms of salpingitis, which are not due to 
upward extension of an inflammation, but are the result of tuber- 
culosis and of appendicitis. With either of these two conditions 
there is a peritoneal involvement associated with the presence 
of tubercle bacilli, streptococci, staphylococci, or bacterium coli. 
These, being drawn up into the Fallopian tubes by the action of 
the ciliated epithelium, produce a salpingitis with a destruction 
of the cilia, or, more frequently, the tubes show constrictions or 
the tube ends are closed and the result is sterility. 

The history of medicine seems to furnish instances where none 
of the above-mentioned causes were responsible for the sterility. 
Here the explanation is referred to a sort of cell incompatibility. 
As illustrations of this condition are given those instances where 
husband and wife have no children, and where after marriage to 
another woman and man each is favored by paternity or maternity. 
Such instances perhaps are to be taken for granted, but their num- 
ber cannot be great. 

Sterility is of two kinds — primary and secondary. Primary 
sterility means that a patient has never been pregnant. Secondary 
sterility means that after a pregnancy (whether it end in abortion 
or at full term) the patient subsequently is sterile, the so-called 
"one-child sterility." 



248 MEDICAL GYNECOLOGY 

Primary Acquired Sterility.— Primary acquired sterility may 
be due to a gonorrhea which has been acute in its manifestations, 
but often is due to a gonorrhea extremely mild in its progress, 
often limited to the tubes, and therefore producing no pain, 
but frequently extending out into the peritoneum. The frequency 
with which cases of primary sterility are treated by dilatation of 
the cervix, and especially by intrauterine manipulations and by 
curettage, accounts for the extension of the mild gonorrheal in- 
fection of the cervix or uterus into the tubes and into the peri- 
toneum. Cases of secondary sterility are not infrequently tem- 
porary, even though they last for years. They are temporary be- 
cause they are not treated. In other words, nature is given a 
chance by her own methods to overcome the inflammation in the 
tubes, and after months or years a partial or complete restoration 
of the ciliated epithelium is accomplished. In primary sterility 
intrauterine manipulation is extremely often attempted. Those 
cases of primary sterility due to mild gonorrheal infection, especi- 
ally those cases in which pain is a symptom, almost universally 
prove to have been curetted, and it is this curettage which is be- 
yond doubt responsible for the permanent nature of the lesions 
producing the primary sterility, because the resulting peritoneal 
involvement which closes the outer ends of the Fallopian tubes 
cannot be relieved by any but surgical methods. 

Repeated Abortion. — A fecundated ovum shows upon its 
outer surface a development of cells known as trophoblast cells. 
It is from these trophoblast cells that the covering of the future 
chorionic villi and placenta are formed. The characteristic of 
the trophoblast cells is that by enzyme action they burrow their 
way into the decidua, digest the tissue in their periphery, perforate 
the blood-vessels, and thus receive their nutrition from the maternal 
circulation. These cells form the two-layered covering of the 
villi, the syncytium, and the cells of Langhans. The uterine lining 
develops into decidua by a great hypertrophy of the connective- 
tissue cells, accompanied by dilatation of the vessels and con- 
gestion of the whole uterus. So delicate is the relation between 
the growing ovum and its trophoblast cells, on the one hand, and 
the decidua and the maternal blood, on the other, that the wonder 
is not that abortion takes place, but that it does not take place more 
frequently. 



STERILITY 249 

Abnormalities in the ovum itself may be the cause of abortion. 
These abnormalities consist first in a syphilitic change. It may 
be taken for granted that an ovum made syphilitic by the fecunda- 
ting spermatozoon produces an abnormal character of cells, and 
the viability of the little embryo is readily affected. If then, at a 
very early stage, there is death of the embryo, or if the cells from 
which the chorionic villi and the future placenta are formed are 
not healthy ones, it can be seen that the relation between ovum 
and decidua may be readily disturbed. The ovum is then a foreign 
body, uterine contractions take place, and abortion results. 

The greater number of abortions, however, result from involve- 
ments of the maternal tissues. Here syphilis of the mother may 
be an influence, in that the processes of placental development are 
carried on in abnormal decidual tissues. There may be, in addi- 
tion, a failure of proper nutrition of the ovum. Endometritis 
implies an involvement of the uterine lining, inflammatory or non- 
inflammatory. It can be seen that an inflammatory involvement 
resulting in great congestion of the uterine mucosa, or resulting 
in atrophy of the uterine mucosa, with or without a change in the 
vessels, destroys the delicate balance between ovum and decidua, 
or fails to give opportunity for sufficient nutrition of the fetal cells. 
Overgrown uterine mucosa in the form of hyperplasia, accom- 
panied as it is with tendency to hemorrhage at menstruation, and 
associated with dilated capillaries and vessels, causes ready cap- 
illary hemorrhage. The growth of the trophoblast cells and the 
extension of the chorionic villi is supposed in every case to per- 
forate capillaries, but if these capillaries are sclerotic or diseased 
ones, or if congestion is marked, too much blood is forced out and 
the ovum is frequently loosened from its contact with the decidua 
serotina or the decidua reflexa. This is perhaps the most fre- 
quent cause of abortion, especially of repeated abortions. 

Changes in the uterine wall may be responsible for abortion. 
A uterus which is inflamed by metritic processes, which is hyper- 
trophied as the result of subinvolution, accompanied as it is by 
congestion and arteriosclerosis, is either stimulated to undue con- 
tractions in the course of pregnancy or else is liable to bleeding 
from brittle arteries. Every uterus, whether pregnant or not, 
undergoes normal painless contractions, which is nature's method 



250 MEDICAL GYNECOLOGY 

of keeping the uterine muscle in good condition. These painless 
contractions continue, and in the latter months of pregnancy are 
known as the Braxton-Hicks painless contractions. An inflamed 
or sensitive uterus reacts by unusual contraction to the presence 
of the growing ovum, and if of sufficiently marked character, re- 
sults in hemorrhage and mechanical loosening of the ovum. 

Secondary Sterility. — Secondary sterility is removed from the 
field of congenital anomalies and is practically always due to an 
inflammatory cause. There are some instances, perhaps, where 
a resulting hypertrophic condition of the endometrium after abor- 
tion or labor may obstruct the entrance of spermatozoa into the 
tubes through overgrowth of the endometrium at the position of 
the internal ostia, but the largest number are due to recognized or 
unrecognized inflammations. The recognized inflammations come 
under the heading of post-partum or post-abortum puerperal 
infections, in which cases there has been an involvement in the 
form of a salpingitis, pyosalpinx, or peritonitis. A very large pro- 
portion of cases, especially such as are not the result of an acute 
septic involvement, are due to the gonococcus. In other words, 
there was in the cervix or uterus a gonorrhea existing before 
pregnancy took place, or acquired subsequent to impregnation. 
On the occurrence of abortion or labor, there takes place a mild 
gradual and often unrecognized upward extension of the inflam- 
mation, which in some instances involves the tubes alone, without 
the production of pain; in other instances involves, in addition, 
the peritoneum, with resulting peritoneal adhesions. These lesions 
are not necessarily so marked as to be easily made out by bimanual 
subsequent examination. Many of these cases have during the 
post-partum state only a minimum amount of uterine discharge, 
often accompanied by only slight rises of temperature, and even 
when sought for the gonococci are found only after most careful 
examination. This is undoubtedly the most frequent cause of 
secondary sterility. 

TREATMENT 

The treatment of sterility should be conservative when inflam- 
mation is evidenced or suspected. Treatment should only be 
radical, so far as operations on the cervix or uterus are concerned, 



STERILITY 251 

when other causes can be eliminated, and when inflammation of 
the cervix, uterus, or other structures can be absolutely excluded. 
In that event dilatation of the cervix, amputation of the cervix, 
or curettage is justifiable. 

General Factors Influencing the Form of Treatment. — If 
we are to concern ourselves with those cases where an acrid va- 
ginal secretion supposedly interferes with the activity of the sper- 
matozoa, we must separate those forms in which we have simply 
an abnormally acid condition, from those in which the vaginal con- 
dition is inflammatory. In the former it is possible that on the use 
of alkaline douches the acidity may be overcome. If, however, 
the inflammatory condition is the responsible factor, it may be 
taken for granted that only in rare instances is this inflammation 
limited to the vagina alone, and for that reason the complicating 
inflammations existing in the area between the cervix and the 
peritoneum are responsible for the sterility. If we are dealing 
with a stenosed external os, with a long narrow canal, with actual 
or relative stenosis of the internal os, and if we can exclude ab- 
solutely the existence of any inflammatory factor, we are justified 
in dilating the cervix. This procedure may be done slowly and 
gradually by the use of cotton wrapped around applicators or 
by the introduction of very fine twists of iodoform gauze in the 
cervix and into the uterus, or by a more energetic dilatation shortly 
before and after each menstrual period, or, finally, by a surgical 
dilatation of the cervix, or, better yet, by a high amputation of the 
cervix. In a certain proportion of cases these procedures result 
in pregnancy, but their number in comparison with the other causes 
is very small. This treatment of the cervix should not be attempted 
in the presence of a cervical or uterine catarrh or if any periuterine 
inflammation is present. 

If we are dealing with a uterus in which an overgrown endo- 
metrium produces presumably very early abortions, and for that 
reason relative sterility, curettage is indicated provided no in- 
flammation exists. If, however, we are dealing with a uterine 
discharge, a catarrhal or gonorrheal endometritis, curettage should 
not be too readily attempted, for it rarely cures the condition and 
we run the risk of sending the inflammation out into the tubes, 
the peritoneum, or the cellular connective tissue. The treatment 



252 MEDICAL GYNECOLOGY 

of these uterine catarrhs should be conservative and intrauterine 
manipulation should be avoided. If, on examination, the tubes 
are found to be enlarged or sensitive, if the ovaries appear to be 
inflamed or fixed, or if peritoneal adhesions involve the tubes, 
ovaries, or uterus, or if a parametritis is present, we have positive 
evidences of the probable existence of a salpingitis with or without 
peritoneal adhesions. Such cases are often produced by intra- 
uterine manipulation carried out for the cure of sterility or by the 
performance of curettage for the cure of sterility. These cases 
furnish a legitimate field for the practice of conservative surgery 
on the adnexa for the purpose of removing the obstruction to the 
exit of the ovum from the ovary or obstruction to the entrance of 
the ovum into the tubes. These cases, since they are inflammatory 
in their etiology, yield poor results, however, from the standpoint 
of cure. For even if the ovary be freed from adhesions, even if 
the outer end of the tube is opened, even if the outer end of an in- 
flamed tube be resected, we are unable by surgical means to re- 
store the lining of the tubes to a normal ciliated action. Hence 
we are compelled before or after operation to resort to those local 
and constitutional hygienic proceedings by means of which the 
natural resistance of the patient is supposed to cast off the products 
of inflammation and restore the tubes to their normal condition. 
This therapy is indicated in those cases where the cervix and 
uterus cannot be made responsible for the sterility and where bi- 
manual examination shows no evidence of peritoneal involvement. 
By this conservative treatment and by avoiding intrauterine man- 
ipulation we may overcome the injury to the cilia of the tubes and 
may prevent the extension of the inflammatory condition to the 
peritoneum and ovary. Even if no evidences of tubal, ovarian, or 
peritoneal inflammation can be made out by bimanual examination, 
and even if pain is not present, sterility must be referred to a sal- 
pingitis if the uterus is normally developed, if menstruation fol- 
lows the normal course, if a dilatation of the cervix has been carried 
out so that obstruction by the external os, by the canal, by the 
internal os, or by acute anteflexion has been eliminated as the 
causal factor. In that event we must give to salpingitis of so mild 
a character as to simply injure the action of the cilia the blame 
for the sterility if active spermatozoa are present. 



STERILITY 253 

The treatment of sterility is divided into (1) the treatment of 
those cases which have never been pregnant, and (2) the treatment 
of those cases which have aborted or have borne one or more chil- 
dren. In the former class of cases treatment is, of course, indi- 
cated only when the presence of active spermatozoa can be de- 
termined. For this purpose coitus, with the use of a condom, 
should be advised as late in the morning as possible, and this con- 
dom with its contained spermatic fluid should be brought as soon 
as possible for microscopic examination. If spermatozoa of an 
active nature are present, treatment may be instituted. 

In cases of hypoplastic uteri treatment is directed to stimulation 
and development of this organ. The general health of the patient 
should be looked after, salt baths or Xauheim baths should be 
given, outdoor exercise advised, and hot douches, consisting of 
several quarts of hot water, should be taken daily. For a long 
period ovarin, 3 to 5 grains three to five times a day, should be 
administered, combined with the sulphate of iron and arsen-hemol. 
In some instances good results have, it is claimed, followed the use of 
the cervical pessary, which stimulates the uterus to contraction and 
auto-massage. By others, the intrauterine application of elec- 
tricity is lauded highly. (See pp. 118,119.) In younger women this 
condition of hypoplasia often rights itself in the course of months 
and years, the outlook being most favorable in those cases in whom 
obesity, if present, diminishes, and in whom the ovaries evidence a 
functional capability, either by marked molimina menstrualia or by 
a fair amount of blood lost during the three to six days of the men- 
strual period. If a normally developed uterus and normally func- 
tionating ovaries are present, treatment should be directed to pre- 
serving the energy of the spermatozoa and to aiding their upward 
course to meet the ovum. With an acid pathologic vaginal, cer- 
vical, or uterine secretion, alkaline and normal saline douches 
should be used to avoid possible injury to the activity of the sper- 
matozoa. Aside from this process, designed to make the vaginal 
canal innocuous, treatment must be directed to diminishing ex- 
cessive or acrid discharge from the cervix or uterus which, by its 
character or copious quantity, may injure or sweep out the sper- 
matozoa as they attempt to enter the uterine cavity. This pur- 
pose is best gained by the use of the method of treatment indicated 



254 MEDICAL GYNECOLOGY 

under cervical catarrh and inflammatory endometritis. It im- 
plies the use of hot vaginal douches, the use of tincture of iodin 
for painting the vault of the vagina, the use of boroglycerin and 
gauze applied liberally about the cervix and to the vault of the 
vagina, and, in some cases, perhaps, it implies the use of intra- 
uterine irrigation. 

In some cases sterility seems to be due to marked acute retro- 
flexion. If such be the case, the use of a Hodge or Smith pes- 
sary or, better still, an Alexander Adams operation, corrects the 
trouble, provided no tubal, ovarian, or peritoneal complications 
are present. Those who practise any of the intraperitoneal meth- 
ods of operation, instead of the systematic use of the Alexander 
Adams operation, will bear witness to the frequency with which 
such retroflexions are found to show inflammatory involvement of 
the tubes and ovaries, with peritoneal adhesions which surround 
the ovaries or shut off the abdominal ends of the tubes. 

Very acute anteflexion, if diagnosed as the cause of sterility, 
may be corrected by intrauterine stem pessary or by amputation 
of the cervix. 

Obstruction by stenosis oj the cervix, by a long narrow cervix, 
or by overgrown mucosa about the internal os demands dilatation 
of the cervix carried out between menstrual periods. This may 
be done under strictest aseptic precautions, in cases free of cervical 
and uterine catarrh, by gently dilating the cervix by applicators 
covered with cotton and dipped into lysol or sterile vaselin. After 
such treatments small wicks of iodoform gauze are introduced into 
the cervical canal and left in place for twenty-four hours. Regular 
dilatation by sounds or by intrauterine electrodes is also of aid. 
If a simple obstruction of this nature is the cause, treatment 
between several menstrual periods should result in pregnancy. 

In the hands of some observers intrauterine stem pessaries worn 
for days or weeks have so removed the obstruction to the spermato- 
zoa as to be subsequently followed by impregnation. By some the 
pessary is made of wire, so that during the period of its application 
access to the uterine cavity is furnished to the spermatozoa. In 
those cases in which, in addition to sterility, there is dysmenorrhea 
due to cervical obstruction or to very acute anteflexion, and in 
which the above-mentioned methods of treatment have failed to 



STERILITY 255 

correct dysmenorrhea, a high amputation of the cervix at the level 
of the internal os is followed by cure of the dysmenorrhea and in 
some cases by impregnation. On electricity, see page 117. 

In the hands of many men many cases of sterility have been 
cured by discission of the cervix and curettage. In some of these 
cases the result has been due to the dilatation of the cervix and to 
the removal of the overgrown mucosa at the level of the internal 
os. In other cases the result has been due to restoration of a nor- 
mal endometrium when hypersecretion from the uterus or atrophic 
or hypertrophic endometrium has prevented the embedding of the 
ovum or has resulted in its habitual early throwing off. 

The majority of instances of primary sterility are due to inflam- 
matory involvements of the lining of the tube or to inflammation 
which closes the outer end of the tubes. Of course, only in those 
conditions in which the outer end of the tube is open can we 
expect correction of the sterility by medical means. It is in this 
class of cases that curetting very often does harm, for it frequently 
results in the upward extension of a uterine inflammation or in 
the aggravation of an inflammation of the tube. This inflamma- 
tory extension often takes place after abortion and labor, and 
results in the so-called "one-child sterility." It certainly often 
occurs after the use of the curet or after intrauterine treatment. 
In many instances all the other possible causes of sterility except 
involvement of the tubal lining can be excluded. Hence, the 
treatment of these cases should be most conservative. Anything 
which improves the patient's general health will aid the system in 
finally overcoming the changes due to bacterial involvement and 
promises the best results. Local treatment should be confined 
to the use of vaginal douches, to the painting of the vault of the 
vagina with tincture of iodin, and to the use of large amounts of 
glycerin about the cervix, supplemented by the packing of the 
fornix and vagina with gauze. Work and marked effort should 
be prohibited. Hydrotherapy is of great aid. (See pages 112- 
115.) Coitus should be avoided as much as possible during 
treatment and rest should be enjoined during menstruation. 
These cases, just as they are greatest in number as the cause of 
sterility, of course furnish the greatest number of failures. The 
prognosis is best in those patients who have not been curetted, 



256 MEDICAL GYNECOLOGY 

who are free of pain in the region of the tubes and ovaries, and 
who show on repeated bimanual examination no tangible altera- 
tions of these organs. 

In the treatment of sterility in which pregnancy once existed 
and was interrupted by abortion, or in the many cases of "one- 
child sterility," there are a few instances in which overgrown 
endometrium or retained decidua obstructs the internal opening 
of the Fallopian tubes and so prevents conception. In such in- 
stances, and in cases of hypertrophic or hyperplastic endometritis 
when inflammation can be absolutely excluded, curettage is indi- 
cated. However, the vast majority of such cases of acquired or 
secondary sterility are due to upward extension of a cervical or 
uterine inflammation which involves the tubes and ovaries in 
tangible or non-tangible inflammation. Such cases, as a rule, 
come to notice not because of the sterility, but because of the pain 
associated with varying degrees of oophoritis, salpingo- oophoritis, 
and pyosalpinx. The treatment of such cases is at first medical, 
local, and conservative, combined with the use of sitz-baths and 
Nauheim baths. 

When all other causes can be excluded by examination and 
treatment, and primary or secondary sterility persists, when active 
spermatozoa are furnished by the male, we then come to the con- 
sideration of intra-abdominal operative treatment for the purpose 
of removing those peritoneal adhesions which cause an obstruc- 
tion which prevents the ovum from entering the tubes. There 
are, however, among such cases many in which, even after loosen- 
ing adhesions or opening the tube-ends, there is still left behind an 
altered inflamed mucosa in the tubes which will prevent the ovum 
from being carried into the uterus. The results of operation done 
for inflammatory disease which closes both tube-ends are not very 
encouraging. Most favorable are those cases in which a long 
period of rest and freedom from intrauterine treatment has followed 
the inflammatory cause of the primary or secondary sterility. 
Still more favorable are those cases in which there has been no 
bilateral or unilateral tubo-ovarian pain. When cases of this 
nature have gone for years without pain or have been treated 
conservatively, it may be taken for granted that the activity of the 
causal micro-organisms has ceased, that they have disappeared, 



STERILITY 257 

and that the natural resistance of the patient has restored the tubal 
lining fairly to the normal. In such cases, when the facts are put 
before the patient and the great possibility of failure has been ex- 
plained, an abdominal operation looking to the removal of adhesions 
and obstructions, to the cleansing of the tubes, and to the for- 
mation of large artificial ostia for the tubes, should be advised. 



17 



FREQUENCY OF MICTURITION; DYSURIA 

Among the annoyances from which women suffer is frequency 
of urination, which, when marked and associated with severe 
contractions of the bladder, is called tenesmus vesicae. The term 
dysuria is applied to the condition where urination is frequent 
and occurs even with little urine in the bladder, occurs also at 
night, and is accompanied by a sensation of discomfort and pain. 
The best and most logical study of the question is made by Winter, 
who looks at the condition with the same analytic eyes as is ob- 
served with dysmenorrhea. Hence the value of the term dysuria. 
There may be constant pain or discomfort in the bladder. Pain 
present before urination may be relieved when the bladder is 
emptied. Pain may be increased during urination. Pain may be 
felt most acutely when urination is completed. 

Frequency of urination may be due to congestive, inflammatory, 
or productive alterations in the urethra, bladder, ureter, and 
kidney, which involve the lining, the wall, or parenchyma, or the 
covering of these organs. The diagnosis of the cause of frequent 
micturition and dysuria is made by inspection, by palpation, by a 
study of the secretion of the urethra, by examination of the urine, 
and by examination of the bladder with the cystoscope. 

CAUSES 

Urethritis. — An acute gonorrheal involvement of the urethra 
in the form of urethritis, especially if the inflammation involves 
the posterior urethra, is associated with frequency of urination, 
with burning micturition, and with a purulent secretion which 
may ofttimes be observed only on massaging the urethra. In the 
chronic form there may be localized or diffuse alterations of the 
urethra, of its lining, and of its follicles, which conditions are pro- 
ductive of frequent micturition, especially if they involve the 
posterior area. The urethrocystic junction may be involved by 
an acute or chronic alteration of inflammatory nature. This 

258 



FREQUENCY OF MICTURITION; DYSURIA 259 

condition is often mistaken for a cystitis. Especially is this the 
case with gonorrhea of the urethra. There are, however, many 
cases in which the urethrocystic junction is seen by the cystoscope 
to be congested and hyperemic, often as a result of a previous 
mild infection, but often without any further evidences of this 
cause. This is productive, in young girls and in younger women, 
of the condition known as irritable bladder. 

In acute urethritis the external os is red and swollen. There is 
purulent discharge and the urethra, when examined through the 
vagina, feels thick and sensitive. Gonococci are readily found. 
The purulent secretion diminishes rapidly within a few days, 
gradually taking on a more epithelial nature, until finally in four 
to six weeks discharge disappears and the condition is apparently 
cured, though gonococci may be present for a long time. They 
are found by gently scraping the urethral canal with a small dull 
spatula. The secretion may continue for months or years, consisting 
mainly of epithelia. This is noted in chronic urethritis, in which 
condition there may be red spots about the external opening of 
the urethra, with involvement of the urethral glands of Skene or 
the periurethral glands. In other cases there is no discharge at all, 
but itching and burning are felt on urination. The sound shows 
the mucosa to be sensitive and its use produces the same sensation 
which the patient feels and complains of on urination. There 
is then either a diffuse involvement of the urethral wall or else 
circumscribed alterations about the lacunae or about the glands of 
Littre. 

In studying urethral alterations the color and the swelling of the 
urethral lining should be observed and the character of the external 
opening and the condition of the ducts should be noted. Palpa- 
tion of the urethra is carried out by passing the finger into the vagina 
or by introducing the sound into the urethra or by the use of the 
endoscope. The sound shows the sensitiveness of the mucosa, 
the presence of irregularities, the existence of narrowing or of 
constrictions. The endoscope is needed only in those chronic 
cases with slight secretion, to reveal the location of circumscribed 
involvements and to diagnose the presence of polyps and tumors, 
especially if there is pain during urination. The examination of 
the urethral secretion should be done after massage of the urethra, 



260 MEDICAL GYNECOLOGY 

the massage being carried out several hours after urination. The 
examination of the urine in urethritis is needed only to exclude 
involvement of the bladder. For this purpose the patient should 
urinate a certain amount in order to clear the urethral canal, and 
the urine should then be drawn from the bladder by the use of the 
catheter. 

Tumors of Urethra. — Under tumors of the urethra Winter 
understands all circumscribed swellings of the mucosa present in 
the urethra or projecting beyond the external opening. Prolapse 
of the urethra should be distinguished by the fact that the ducts of 
Skene are readily seen, and by the fact that by proper manipulation 
the mucosa which is prolapsed in its entire circumference or only 
on its posterior wall may be replaced within the canal. Condylo- 
mata may be present about the external opening of the urethra. 
There may be caruncles or polyps in the urethra. Caruncles are 
new formations growing out from the urethral mucosa and filled with 
numerous capillaries and very red in appearance. Some of them 
contain so many nerve filaments that the slightest touch causes 
exquisite pain. There may be a diffuse carcinomatous infiltra- 
tion. These various forms of growth may produce marked cramp- 
like pains on urination, which sometimes extend into the vulva 
and anus and even into the hips. Sometimes they are associated 
with tenesmus of the sphincter ani. 

Pericystic Conditions. — Conditions outside of the bladder are 
responsible for frequent urination and pains. A parametritic 
exudate may press against the bladder wall; the mucosa is ar- 
ranged in thick folds in this area; the mucosa is edematous and 
is covered with minute vesicles — the so-called oedema bullosum 
of Kolischer. The same change is produced by some cases of 
pyosalpinx. Other diseases of the genitalia may produce annoy- 
ances in the bladder. The congestion induced by pregnancy plus 
the pressure of the pregnant uterus, the presence of small cervical 
or large uterine myomata, the existence of a retroflexion, various 
tumors of the adnexa, a large hematocele or a peritoneal exudate, 
have a congestive and pressure influence on the bladder. The 
bladder is involved by hyperemia in many cases of metritis, para- 
metritis, and perimetritis. These conditions do not cause the pain 
noted in cystitis, but are responsible for frequent micturition. 



FREQUENCY OF MICTURITION; DYSURIA 261 

Hyperemia of Bladder Mucosa. — In involvement of the 
bladder mucosa of a congestive hyperemic nature frequency of 
micturition results, more especially if the trigone or the urethro- 
cystic junction is involved. This may be caused by drugs taken 
internally, by the irritating influence of certain articles of food, 
by inflammation about the bladder, by the pressure of exudates 
or tumors about the bladder, by masturbation, and by the conges- 
tion of menstruation and pregnancy. Hysteria and neurasthenia 
are conditions not infrequently associated with frequency of 
micturition. In the so-called "irritable bladder" there are con- 
gestive changes in the area of the trigone and especially at the 
urethrocystic junction. These points are very sensitive, and 
during the daytime, when the patient is in the standing position, 
urination is very frequent, but at night little or no annoyance may 
be felt. Many of these cases are probably the result of previous 
infections which leave behind only this congestive, hyperemic, 
sensitive alteration. 

In that frequent form of bladder involvement which affects the 
trigone and which is known as hyperemia or a neurosis or irritable 
bladder, there is only a simple hyperemia of the trigone, as seen in 
pregnancy and pelvic disease, due to dilatation of the blood- 
vessels as the result of increased blood-supply in the pelvis. Hy- 
peremia often disappears on removal of the cause, but chronic 
inflammation of the trigone not so easily. A distinction between 
a hyperemia and a real trigonitis is often difficult. 

Cystitis. — The causes of cystitis are as follows: (i) Infection 
per urethram, such as cystitis gonorrhceica, the cystitis occurring 
post partum, and catheterization cystitis; (2) bacteria coming 
from the intestines, through the circulation or through the kidneys. 
Special forms are cystitis resulting through stone or neoplasms, 
and tubercular cystitis, descending from the kidney as a rule. 

Bacteria of Cystitis. — True inflammation of the bladder is 
produced by bacteria introduced through the urethra or eliminated 
through the kidney, descending from the kidney in pyelitis, pye- 
lonephritis, pyonephrosis, or tuberculosis. Bacterial infection is 
evidenced by the additional symptoms of pain and pyuria. Bac- 
teria which may enter through the urethra are the bacterium coli, 
tubercle bacillus, the gonococcus, streptococcus, staphylococcus, 



262 MEDICAL GYNECOLOGY 

and yeasts. Bacteria may be introduced by the catheter, resulting 
in catheterization cystitis. Bacteria, however, may enter, and 
frequently do so, without this mechanical aid, as can be seen 
from the extension of a gonorrheal urethritis. This bladder in- 
volvement per urethram not infrequently takes place with profuse 
pathologic discharge from the vagina, cervix, and uterus. The 
bacterium coli, especially in older women with lacerations of the 
perineum and uncleanly personal care, comes directly from the 
rectum. Involvement of the bladder by the colon bacillus is not 
rare in older women, and is comparable to senile vaginitis, where 
tissues of little resistance permit of bacterial invasion and growth. 

Alterations in the Mucosa in Acute Cystitis. — Seen through 
the cystoscope, the normal mucosa of the bladder is very pale in 
color. There is a slight yellowish-rose tint. There are numerous 
delicate vessels which in various spots resemble a picture of the 
retina. In inflammation the mucosa is redder than normal. 
There is a diffuse capillary injection and an increase and dilatation 
of the larger vessels. These changes diminish the extent of the 
normal pale area of the mucosa. 

In acute cystitis there is a strong vascularization and filling of the 
vessels, especially near the neck of the bladder and in the trigone. 
The mucous membrane is edematous, hyperemic, and shows 
ecchymoses. The epithelia become destroyed and are mixed 
with the urine. In severe cases there is small-celled infiltration of 
the mucosa and the muscularis. 

At various points the mucosa is red in spots or in larger areas. 
At those points where purulent exudate or tumors compress the 
bladder wall the small vesicles described by Kolischer are present. 
According to Kolischer, gonorrheal inflammation of the bladder 
shows numerous inflamed red spots, about which the bladder 
mucosa seems normal. In inflammation of the bladder much 
of the mucosa may be covered by attached mucus. 

In severe cases, especially with gonorrhea and tuberculosis, 
ulcerations may be present. Tuberculosis of the bladder occur- 
ring from infection of the kidney shows most marked involvement 
in the neighborhood of the ureter. There may be miliary nodules 
grouped together and surrounded by areas of injection. There 
may be ulcerations of small character or there may be a large area 



FREQUENCY OF MICTURITION; DYSURIA 263 

of ulceration, especially marked around the opening of the ureters. 
The cystoscope divulges congestion of the mucosa, roughening of 
the mucosa, edema of the mucosa, the presence of vesicles, tubercles, 
and ulcerations. 

Gonorrheal Cystitis.— Gonorrheal cystitis appears under the 
form of cystitis colli. There is frequent desire for urination and 
very severe pain, especially at the end of urination. Pus and also 
blood are in the urine. Frequency of urination is more marked 
than in all other acute forms and may occur every five or ten min- 
utes. 

Acute gonorrheal cystitis is either catarrhal or purulent. The 
catarrhal form produces an acid urine containing mucus, large 
bladder epithelia, and many micro-organisms. The urine of the 
acute purulent form has a neutral or alkaline reaction, contains 
pus cells, numerous micro-organisms, and many bladder epithelia. 
If alkaline, the urine may have a foul smell. 

The chronic form results subsequent to an acute infection and 
may present objective evidences of the above nature with but few 
subjective evidences. In the alkaline form the urine should be 
kept acid by the administration of salicylic acid. 

Gonorrheal urethrocystitis causes frequent micturition, worse 
by day. The second urine is much clearer and the urine is acid. 

Idiopathic Cystitis. — So-called idiopathic cystitis occurs readily 
in women because the short urethra allows bacteria to enter the 
bladder, especially in association with pregnancy and post partum. 
The diagnosis between cystitis and pyelitis is made partly by the 
therapy. Every cystitis except the tubercular form and the form 
associated with malignant growths improves by treatment of the 
bladder, whereas pyelitis does not. The characteristics of so- 
called " idiopathic cystitis " are the same as in the following form. 

Catheterization Cystitis. — Catheterization cystitis is not in- 
frequent after labor and operation. The urine is cloudy, con- 
tains pus cells, numerous bacteria, and mucus, and frequently 
undergoes ammoniacal degeneration. Normal urine is slightly 
acid, ammoniacal urine is alkaline. The colon bacillus does not 
cause ammoniacal degeneration, hence the reaction of the urine 
in colon bacillus cystitis is acid. The same is true, as a rule, of 
the gonococcus form of chronic cystitis. In tubercular cystitis 



264 MEDICAL GYNECOLOGY 

the urine is also acid. The various forms of staphylococci are the 
cocci generally responsible for ammoniacal degeneration of the 
urine. In addition, this condition is caused by the proteus vulgaris 
of Hauser. 

Alterations in Chronic Cystitis. — In the chronic cases the 
main changes are in the trigone and at the neck of the bladder. 
The mucous membrane is gray, swollen, thickened, succulent. 
Epithelium is gone in the upper layers and there is round-celled 
infiltration in the submucosa. There may be seen typical granu- 
lations or more marked round excrescences, or else villous out- 
growths. In extremely severe cases ulcerations may occur. 

In very chronic cases the bladder wall, instead of being up to 
10 mm. in thickness, is often 2 to 3 cm. thick. The bladder wall 
shows changes in the interstitial tissue, which is increased. This 
condition constitutes a fibrosis, according to Garceau. In the 
earlier stages there is total or partial desquamation of the epithe- 
lium, and later on the whole internal coat is cast off, leaving only 
a connective-tissue lining. Sometimes the epithelium instead of 
being cast off proliferates, forming patches of leukoplakia or papil- 
lary glandular plaques giving the trigone and vesical neck a villous, 
velvety look. Occasionally small cysts are formed. If necrosis 
of the superficial layers takes place, we have a membranous cystitis. 
The commonest lesion is hypertrophy of the muscle wall. 

Trigonitis. — A frequent form of cystitis is that which affects the 
trigone, and is often called hyperemia or irritable bladder. There 
is frequently a simple hyperemia of the trigone, seen in pregnancy 
and pelvic diseases, due to dilatation of the blood-vessels as the 
result of increased blood-supply in the pelvis. Hyperemia often 
disappears on removal of the cause, but chronic inflammation of 
the trigone not so easily. A distinction between a hyperemia 
and trigonitis is often difficult. In severe cases not only the trigone, 
but the vesical neck and the urethra, have a characteristic scarlet 
red appearance. The urine is not much altered in these cases, 
but careful examination shows excess of epithelial cells, some 
blood and pus, and various bacteria. Two-thirds of the bladder 
involvements in women are this chronic inflammatory trigonitis. 
In the later stages there may be proliferative processes leading to 
the formation of papillary or warty excrescences which show 



FREQUENCY OF MICTURITION; DYSURIA 265 

marked round-celled infiltration and change of the cylindrical 
epithelium to squamous. 

Shrunken Bladder. — In the chronic forms, resulting from 
neglected uncured cases of cystitis, there may be huge muscular 
hypertrophy of the bladder wall. The hypertrophy of the wall 
results in diminution of the cavity of the bladder; the bladder 
holds little urine and is much contracted, so that the capacity is 
limited to ioo grams or less. This is the "shrunken bladder," 
which must be treated by gradual repeated distention. 

Tuberculosis. — Primary tuberculosis of the bladder is doubtful. 
It is a question whether tuberculosis is really ever primary in 
the bladder. In the opinion of Garceau, it is practically always 
secondary to some lesion situated elsewhere in the body which 
serves as a primary focus. It is usually secondary to tuberculosis 
of the kidney. Clinically, however, there are many cases in which 
the bladder lesion is the only important one. Vesical tuberculosis 
is first miliary in form; second, ulcerative. In the miliary form 
the cystoscope shows numbers of small red patches in which the 
tubercles are later to appear. In the early stage there are small 
gray nodules, sometimes isolated, sometimes grouped, giving the 
impression of follicles. Inflammatory reaction results and the 
tubercles undergo degeneration, become soft, and there finally 
results ulceration. Around the ulcerations there are inflammatory 
areas. There is much vascularization and ecchymosis. In 
advanced cases the process goes deeper than the surface, the 
bladder muscle is thickened and shrunken, and the lumen of the 
bladder is much diminished. The various stages are gray nodules, 
yellow nodules, small areas of softening, larger confluent ulcers, 
secondary inflammation of the mucosa and muscularis. As 
almost all cases are of the descending form, the earliest nodules 
are seen near the openings of the ureters. Later on the condition 
becomes more general. The trigone, the area from the ureters 
to the neck of the bladder, is the favorite point of location, although 
tubercular areas may occur elsewhere. 

Stone and Neoplasm. — Stone in the bladder in women is 
rare. The proportion of women affected compared with men is i 
to 200. Foreign bodies in the bladder may be introduced in 
attempts at masturbation. Tumors of the bladder occur most 



266 MEDICAL GYNECOLOGY 

often in the neighborhood of the ureters and near the internal 
sphincter. 

DIAGNOSIS 

The three important symptoms of cystitis are: (i) Frequency 
of urination; (2) pain; and (3) pus in the urine. The more acute 
the process, the more marked are the first two symptoms. 

The normal bladder feels the desire to be emptied when between 
300 and 500 c.c. are present. In cystitis frequency of urination 
exists with small amounts of urine in the bladder. This desire 
exists by day and by night. In the nervous form of frequent 
urination there is little or no annoyance at night. 

Pain. — In cystitis pain may occur before, during, or after urina- 
tion. In acute cases the pain lessens as soon as the bladder is 
empty. In many cases, especially if the lesion is near the neck 
of the bladder, the pain is felt at the end of urination. 

In discussing the pain associated with urethral or bladder con- 
ditions we find that pain may come on during urination, may 
become worse on urination, may be relieved by urination, or may 
be felt most markedly after the bladder is emptied. Constant 
pain means a cystitis and perhaps a pericystitis. Pain present 
before urination and which is relieved by urination is due to the 
bladder. Pain made worse during urination is due to urethral 
causes. Pain felt most after urination is completed is probably 
due to pelvic peritonitis and adhesions to the bladder which are 
made tense by contraction of the bladder. 

Purulent Urine. — There are, as stated, very slight forms of 
inflammation with hyperemia of the mucosa in which there is no 
pus. As a rule, there is no cystitis without pus in the urine. 

The last urine passed contains the most pus. The more diffuse 
the process, the greater the amount of pus. Blood in general is not 
a constant symptom of cystitis. In diagnosing involvements of 
the bladder, examination of the urine is of importance. The 
urine should be withdrawn by the catheter and allowed to stand 
in a urine glass for several hours, or, better still, should be centri- 
fuged. The best procedure is to centrifuge a large amount of 
urine. The sediment should be examined. If the sediment 
does not dissolve on heating a specimen of urine or on the addition 



FREQUENCY OF MICTURITION; DYSURIA 267 

of acetic acid, it is composed of pus or epithelium or blood or bac- 
teria, or combinations of these elements. If it is increased by heat- 
ing and does not disappear on the addition of nitric acid, we have 
the usual test for albumin. The microscope aids in the finding 
of pus cells, of epithelia, of blood, of bacteria, and of urine crystals. 
The bacteria most sought for are the gonococci and the tubercle 
bacilli. 

Continued purulent discharge from the bladder which resists 
treatment, especially if there is pain in the region of the kidney, 
demands careful microscopic examination, a staining for tubercle 
bacilli, and the use of the cystoscope for the purpose of catheteriz- 
ing the ureters. 

Chronic cystitis is the most frequent cause of dysuria. When- 
ever the urine, in any but an acute cystitis, contains much pus, 
the cystoscope should be used with or without catheterization of 
the ureters. Blood may be present in acute cystitis mixed with 
pus. In other conditions, especially if there is blood without the 
presence of pus, a severe affection or new-growth of the bladder or 
kidney is probable. 

If none of the above causes are present, and if diseases of the 
ureter, the pelvis of the kidney, and the kidney itself can be ex- 
cluded, we may come to the conclusion that frequency of micturi- 
tion is due to a general or a local neurosis or to "irritable bladder." 

The retroflexion of a gravid uterus may bend the urethra, 
compress it against the symphysis, and result in a tremendously 
dilated bladder, from which the urine dribbles. Infection of such 
a bladder may cause a necrosis of the mucosa. 



SYMPTOMS OF TUBERCULAR CYSTITIS 

In the early stages when the process descends from the kidneys, 
there is increased frequency of urination and perhaps bleeding. 
Frequency of urination is not very great and pain is slight. The 
urine in this period is very clear, but at times there may occur 
bleedings of short duration, and usually at the end of urination 
and not affected by activity or rest. 

When in the course of a few months around the circumscribed 
areas there develops a tubercular cystitis, there is frequency of urina- 



268 MEDICAL GYNECOLOGY 

tion, pain on urination, and pus is sometimes found in the urine. 
The frequency of urination is very marked and is uninfluenced by 
treatment, especially if the condition has advanced over the trigone 
to the neck of the bladder. Urination is then accompanied by 
pain at the end of micturition. The bladder contracts in tenesmus. 
The urine is acid (which is also true of most forms of cystitis). 

Tuberculosis of the bladder is generally secondary to tuberculosis 
of the kidneys and ureters. The cystoscope shows tubercles and 
ulcerations. Miliary tubercles may be present in the base of the 
bladder, about the ureters, or diffusely scattered. There is fre- 
quency of micturition at night. Pain comes on gradually and is 
noted in urination or may be more or less steady. When cheesy 
degeneration of the tubercles occurs, pus appears. The symptoms 
are those of a chronic cystitis. 

The amount of pus is fairly large, for, in addition to the localized 
processes, the entire bladder is inflamed. The occurrence of 
blood, even if only in the form of red blood-cells recognized by the 
microscope, is almost always noticed in tuberculosis. The tubercle 
bacilli can be found in 80 per cent, of the cases and must be dis- 
tinguished from the smegma bacilli. 

Tuberculosis should always be suspected, especially in younger 
women if other causes are absent. There is frequency of urination, 
pyuria, pain on pressure and examination. The tubercle bacilli 
should be looked for. The cystoscope should be used and guinea- 
pigs should be inoculated. According to Kolischer, urinary 
tuberculosis is a disease of young adult women, generally occurring 
in the kidney primarily, and unilateral. Bladder symptoms are 
the first cause of complaint. The kidney involvement must be 
diagnosed from appendicitis and gall-stone colic. In about half 
the cases heredity is concerned in the etiology. 

In those cases in which tubercle bacilli cannot be found the fact 
that other bacteria are not present is of importance. Tuberculous 
urine in which no tubercle bacilli are found is characterized by 
the fact that, not always but very often, no other bacteria are 
present. In contrast with other forms of cystitis, no etiology is 
evident. The pain is generally excessive. The bladder is intol- 
erant of large amounts of fluid injected. If cystitis therapy does 
not improve a bladder disease, tuberculosis is to be suspected. A 



FREQUENCY OF MICTURITION; DYSURIA 269 

condition of "cystitis" which does not improve under nitrate of 
silver, but which grows worse, is either tuberculous cystitis or 
pyelitis. The cystoscope is essential to the making of the diagno- 
sis in doubtful cases. 

TREATMENT OF CYSTITIS 

Acute cystitis should be treated by the internal administration 
of salicylic acid or salicylate of soda, or salol 5 grains every three 
hours. The use of salol results in the liberation of carbolic acid 
and salicylic acid in the urine. Urotropin is a very valuable 
urinary antiseptic, especially as an adjunct to salol in dose of 5 
grains every three hours. It is of great importance in the chronic 
forms. Helmitol, 15 grains three times a day, gives off more 
formaldehyd in the urine than does urotropin and acts even if 
the urine is not acid. Saliformin, 5 grains every four hours, is a 
valuable urinary antiseptic. A favorable combination consists 
of sodium salicylate, 1 dram; urotropin, ij drams; tincture of 
hyoscyamus, 4 drams; elixir simplex, q. s. ad. 4 ounces; 1 dram 
of this mixture being given in water several times a day. Benzoic 
acid, 10 grains three times a day, in capsules, checks fermentation 
and is a local alterative and antiseptic. It acts well in gonorrhea 
and especially well in ammoniacal cystitis. Methyl-blue, 5 grains 
several times a day in capsules, is only mildly antiseptic, but is 
of aid in the non- gonorrheal forms. 

1^. Acidi benzoic 3 j 

Syrup, aurant. cort 3 v 

Aq. destil 5 viij 

S. — One tablespoon every two hours. 

1$. Acidi salicyl 3iv 

Div. in dos. xii. 

S. — One powder t. i. d. with water. 

I?;. Sodii salicylatis 3iss 

Urotropin 3iss 

Tinct. hyoscyam 3iv 

Elixir simplex, q. s. ad oiv 

S. — 3j in water every two hours. 

1^. Salol gr. v 

Urotropin gr. v 

Ft. tal. caps. no. xii. 

S. — One every four hours with water. 

The pain associated with acute cystitis may be relieved by a 
suppository containing i grain of extract of opium and i grain of 



270 MEDICAL GYNECOLOGY 

extract of hyoscyamus in ol. theobroma. If this does not relieve 
the pain and spasm, morphin must be given by the needle. The 
fluidextract of uva ursi, 2 drams three times a day, is a slight 
stimulant and astringent and is of value in the early stages. The 
fluidextract of kava-kava, \ dram three times a day, is highly 
comforting, especially in gonorrheal cystitis. In the later stages 
we may use t. i. d. gonosan capsules which contain 20 per cent, 
of kava and 80 per cent, of sandalwood oil. Balsam of copaiba, 
15 grains in capsules, is a local stimulant to the mucous membrane. 

1^. Ext. opii gr. v 

Ext. hyoscyam gr. v 

Ol. theobrom. q. s. 
F. suppositor. rectal, no. v. 
S. — One morning and night for pain. 

1$. Ext. cannab. ind gr. v 

Ext. hyoscyam gr. v 

Sacch. lactis 3 j 

M. f. pulv. Div. in dos. x. 

S. — Three to five powders daily for pain. 

1^. Syr. papaveris 3iss 

Infus. fol. uvae ursi §xij 

S. — One tablespoon every one or two hours for pain. (Finger.) 

Among the other drugs taken internally are the alkalies, which 
should be given in gonorrheal cystitis only if the urine is very acid, 
and never enough to render the urine alkaline. The best of the 
alkalies is citrate of potash. This may be prescribed in the form 
of: 

1^. Liquor potassii citratis 3 vj 

S. — One tablespoon every two hours. 

Or: 

1^. Potassii citras effervescens §iij 

S. — 3ss in water every two hours. 

The bottled waters of Giesshubl and Wildungen may be used; 
or: 

1$. Potass, bicarb - - o j 

Tr. hyoscyam. 

Ext. kav. kav. fi aa 3 ss 

Aq oviij 

S. — oss two hours after meals. 

The alkalies are of value in some cases of acid cystitis, and in 
those cases of irritable bladder which are associated with acid 
urine. They should be used in gonorrheal cystitis only to 
diminish very marked acidity. 



FREQUENCY OF MICTURITION; DYSURIA 271 

The local treatment of acute gonorrheal cystitis applies to acute 
cystitis due to other bacteria as well. A preliminary washing of 
the bladder is of value to remove pus and bacteria. Normal salt 
solution, 2 drams of salt to the quart, or a mild boracic solution, 
1 per cent., are used for the preliminary washing, either of which 
fluids have a non-irritating influence on the mucous membrane. 
The preliminary irrigation should be followed by irrigation with 
fluids which have a destructive action on the bacteria and which 
exert a stimulative influence on the epithelium, and so aid in the 
throwing off of bacteria. Protargol, while not quite so valuable 
in this respect as silver, is much less irritating and should be used 
in the acute stages. Protargol works well in the diluted strength 
of 1 : 800 up to 1 : 100 in the acute stages, and from i to 5 per cent. 
in the more stubborn cases. Several ounces are to be injected 
into the bladder and allowed to remain for five to ten minutes. 
If the bladder is extremely sensitive, it should be first anesthetized 
by injecting into the bladder an ounce of a 1 per cent, solution of 
eucain or of a 4 per cent, solution of antipyrin, which should be 
left in place for several minutes. In the subacute stages or in 
stubborn cases nitrate of silver diminishes congestion and stimu- 
lates regeneration, as well as being a very valuable germicide. 
When used in solutions of 1 : 10,000 and gradually increased to 
1 : 500, and in very stubborn cases even 1 : 100, it renders the 
urine clear. If too annoying, it should be preceded by the use of 
an anesthetizing solution. The strength of any of the irrigations 
depends upon the sensitiveness of the bladder, which can be 
judged by the preliminary washing with saline or boracic solution 
and by the amount which the bladder can hold when this pre- 
liminary solution is injected (Fig. 30). 

In the milder stages, cystitis may be treated by irrigation with 
0.5 per cent, salicylic solution or by 2 per cent, resorcin solution, 
which are mildly germicidal. Permanganate of potash is an 
antiseptic of value and may be used in the strength of 1 : 10,000. 
Ichthyol 1 per cent., when allowed to remain in the bladder for 
fifteen minutes, is an excellent drug. 

In chronic cystitis nitrate of silver 1 : 3000 or 1 : 500 should 
be used every other day. The stronger solutions or instillations 
must be preceded by an anesthetizing irrigation. 



272 MEDICAL GYNECOLOGY 

In chronic cystitis urotropin has a splendid effect. While 
urotropin, salol, and helmitol (helmitol acts in an alkaline urine) 
are splendid urinary antiseptics, yet in many of the cases of chronic 
cystitis with acid urine the urine must be rendered less acid or else 
alkaline. 

Cases of chronic cystitis with shrunken bladder must, in addition 
to the use of silver, etc., be treated two or three times a week by 
the injection of boracic solution under the pressure of a syringe 
up to the full capacity of the bladder. At each successive treat- 
ment more should be injected, so that in the course of weeks or 
months the capacity of the bladder is increased. These are cases 
of old, long-neglected cystitis with marked hypertrophy of the 
bladder wall. Treatment of such cases takes months or years. 
General tonic treatment, rest, and plenty of fresh air are essential 
in benefiting many cases of chronic cystitis. 

There are many cases of so-called irritable bladder where exami- 
nation with the cystoscope shows the involvement to be limited 
to the area of the trigone. Those cases in which there is simply a 
slight hyperemia of this area, or of the urethrocystic junction, 
belong to the class known as irritable bladder. In many of these 
cases, however, the lesions in the area of the trigone are more 
marked, and interstitial or productive changes are present. These 
cases of "trigonitis" are usually the result of old neglected cases 
of gonorrheal or other forms of cystitis. In the treatment of such 
cases the various silver salts give the best results. 

The treatment of simple "irritable bladder" is as follows: 
The bladder is thoroughly irrigated with a strong solution of 
boracic acid through a catheter. After irrigation with boracic 
acid solution the bladder is then emptied and 8 ounces of a 1 per 
cent, watery solution of ichthyol are introduced, which the patient 
is to retain for one-half hour, if possible. This treatment is con- 
tinued every other day. If this fails mild solutions of silver nitrate 
must be used. For internal medication I prefer seven grains of 
urotropin four times daily, or else, with very acid urine, citrate of 
potash several times daily. In the milder forms of irritable 
bladder Wildungen water without local treatment arrests the acid- 
ity of the urine. 

In every case with symptoms of cystitis disease of the kidneys 



FREQUENCY OF MICTURITION; DYSURIA 273 

should be excluded. In cystitis of uncertain etiology any urine 
which, in spite of treatment, shows pus or blood should be examined 
for tubercle bacilli. Pus in the urine without the finding of the 
usual pus micro-organisms speaks strongly for tuberculosis. In 
the treatment of vesical tuberculosis removal of the diseased kidney 
is an important factor and subsequent treatment of the bladder is 
most essential. In addition to relieving the patient of the dangers 
and tremendous annoyance of vesical tuberculosis, it must be 
borne in mind that the ureter of the sound side may become in- 
volved by upward progress of the tubercular process from the 
bladder. According to Klotz, Rovsing treats tuberculosis of the 
bladder as follows: The bladder is first irrigated and then 50 c.c. 
of warm 5 per cent, solution of carbolic acid is injected and allowed 
to remain for three or four minutes. If it returns turbid, the 
method is repeated until it returns clear. A rectal suppository con- 
taining J to 1 grain of ext. opii is introduced to lessen the pain 
which occurs two or three hours after the treatment. The treat- 
ment is repeated every other day until the urine remains fairly 
clear between treatments, and then the interval is gradually 
lengthened. Treatment lasts from one to six months. Often no 
benefit is obtained from treatment unless the diseased kidney is 
removed. To determine which kidney is involved, catheterization 
of the ureters is necessary. 

According to the experience of Guyon and Casper, instillations 
of corrosive sublimate are used in the bladder twice a week, or 
even every day if possible, for the treatment of tuberculosis of the 
bladder. Thirty drops are introduced into the bladder by a 
long pipet, beginning with a solution 1 : 20,000 to 1 : 10,000 and 
gradually increasing the strength to 1 : 500, which is rarely possible. 
To avoid marked pain, eucain and cocain should be used before 
the instillation of corrosive sublimate. 

In every case of possible tuberculosis, especially if the cystoscope 
is not used or when the cystoscope shows the bladder to be sound, 
a specimen of urine should be drawn from the bladder by catheter 
under aseptic precautions and sent to a pathologist for guinea-pig 
inoculation, even though it takes five weeks to receive a report. 

In the treatment of those cases of irritable bladder due to or 
associated with pelvic inflammation or uterine displacements, 



274 MEDICAL GYNECOLOGY 

the bladder should be treated as described above, and ofttimes 
with good results. In some instances, however, no improvement 
of permanent nature results without treatment and medical or 
surgical correction of the pelvic disease. In the treatment of 
irritable bladder, due to a general nervous condition or to hysteria, 
the use of alkalies to combat the acidity of the urine, and general 
treatment for the condition, are the modes of procedure. - 

For the treatment of urethritis see Gonorrheal Urethritis, p. 375. 

In the treatment of those conditions of the urethra involving 
productive changes, such as caruncles, polyps, etc., their removal 
by cautery or knife is the proper treatment. Local treatment by 
ichthyol, silver salts, by urethral irrigation, or the use of medicated 
pencils ofttimes brings relief (page 379). 



ASSOCIATED NERVOUS CONDITIONS IN GYNECOLOGY 

PUBERTY 

Constitutional Changes Produced by the Ovaries. — Marked 
constitutional changes occur at puberty, during menstruation, 
during pregnancy, and at the menopause. The relation between 
the changes occurring at puberty and at the menopause, before 
menstruation, and -after menstruation, during pregnancy and after 
pregnancy, show a decided resemblance. Until shortly before 
each menstrual period, temperature, pulse, muscular activity, 
lung capacity, and the excretion of urea increase, and reach their 
maximum two or three days before the appearance of blood. 
During this period we find hyperemia, edema, increased activity 
of the ovary, changes in all the mucous membranes, and increased 
function of all the glandular apparatus. These and the occurrence 
of swelling of the breasts, tenderness of the abdomen, even pain, 
and the passage from the vagina of greater amounts of mucus, some- 
times mixed with blood, prove at the beginning of each menstrual 
period a wave movement and increased general blood-tension due 
to the ovaries and their secretion. During and after menstruation 
regressive changes are evident. 

During pregnancy we have an increased amount of the watery 
elements of the blood, an increased proportion of fibrin, a dimin- 
ished amount of albumin, an increase in the white blood-cells, 
a relative diminution in the number of red blood-cells and in the 
amount of hemoglobin. 

Before labor the temperature is higher in the last three months 
of pregnancy, and there is an increase in the elements of the body, 
equal to one- thirteenth of the body- weight. This increase is due 
in part to serous infiltration, and to the increased ability of the body 
to form organized tissue. Post partum, after a temporarily short 
rise, the temperature is lower, the blood-pressure sinks, and becomes 
normal on the ninth day. After labor there is a diminution of 
tissue change and a diminution in the amount of urine. 

2 75 



276 MEDICAL GYNECOLOGY 

As regards temperature, blood-pressure, hyperemia, the amount 
of urine secreted, etc., there is always a similar increase before 
menstruation, and a like decrease in intensity during and after 
menstruation, as during and after parturition, so that Virchow 
has well characterized menstruation as a labor en miniature. 

NERVOUS SYMPTOMS AT PUBERTY 
There is marked development at puberty in the female, which 
occurs earlier than in the male. This period, from the thirteenth 
to eighteenth years, is a trying one for the girl, and is characterized 
by diminished general resistance. The increased blood-supply 
in the genital area, and the increased arterial tension produced by 
the ovaries and their internal secretion, cause at puberty backache, 
a sense of drawing in the back, sensations of pressure in the pelvis 
and in the region of the uterus and ovaries. There is a feeling of 
weight and weariness in the lower extremities. Girls may become 
suddenly pale or red, alternately hot and cold. There is sometimes 
a slight rise in temperature. There are changes in the activity 
of the intestines, bladder, and stomach. Most marked is an 
irritability of the nervous system. There is a tendency to depres- 
sion and " blues." The nervous system is often affected even 
before the establishment of menstruation, and among the symp- 
toms may be headache, lassitude, irritability, rings under the eyes, 
general discomfort, epigastric pain, loss of appetite, palpitation 
of the heart, dizziness, weakness, and weight in the lower extremi- 
ties. All this may last for months and may weaken the general 
system and diminish its resistance. 

Among the prodromal symptoms are swelling of the breasts, 
meteorismus, watery, mucoid vaginal discharge, pruritus vulvae. 
Any or all of the above symptoms may be magnified in any case 
and result in severe abdominal pain, in general weakness, marked 
dyspnea, diarrhea, headache, neuralgia. They are due to the 
menstrual stimulus produced by the functionating ovaries which 
are bringing follicles to full development and are producing 
a general constitutional hyperemia. During this period the rela- 
tion between the ovary and other organs, especially the thyroid 
gland, is being worked out either easily and harmoniously, or with 
marked difficulty. 



ASSOCIATED NERVOUS CONDITIONS 277 

Cardiac Symptoms at Puberty. — Among the cardiac symptoms 
noted at puberty is nervous heart palpitation, often in girls who are 
not anemic and who have no disease of the heart or the vessels. It 
is related to the changes occurring in the genital sphere because it 
comes on with force a few weeks or months before the establish- 
ment of menstruation, occurs irregularly, lasts beyond the first 
menstruation, but disappears when regular menstruation is finally 
established. It is of four forms and is probably related in part to 
thyroid overactivity. 

In the first, the pulse is rapid — between 120 and 140. It comes 
on at irregular intervals without cause or after slight excitement. 

The second form shows a tachycardia, very rapid; it is pre- 
menstrual and comes on before the establishment of the first 
menstruation, but recurs regularly every three or four weeks 
before menstruation or during the menstrual period and lasts 
but a few days. 

In the third form the condition is noted in girls in whom men- 
struation begins late, at eighteen, nineteen, or twenty, or in girls 
in whom there is irregularity of menstruation. Here the cardiac 
symptoms are sometimes marked. There is a decided and fre- 
quent palpitation and throbbing in the carotids. The skin is 
pale, there is diminished hemoglobin, there is asthenia, and ner- 
vousness. We have the picture of the chlorotic habit, often 
combined with evidences of the anemic form of lipomatosis uni- 
versalis. There is often acne vulgaris, comedones, sweating of 
the hands, blueness of the nose and ears. 

The fourth form is noted in girls who grow rapidly before the 
first establishment of menstruation. They are not anemic or 
nervous, but are usually very thin. There is palpitation, shortness 
of breath when active. The heart, in contradistinction to the 
other three forms, shows enlargement, and there is hypertrophy 
especially of the left ventricle. Here development in the genital 
sphere has caused a storm in the vessel system which produces 
increased resistance to the work of the heart; the rapid growth 
of the body increases the heart's work. Corsets create frequently 
an obstacle to the development of the rapidly growing body, the 
thorax, the breasts, and the upper abdomen, and add to the burden 
placed upon the heart (Kisch). 



278 MEDICAL GYNECOLOGY 

The Influence of Psychic Stimuli at Puberty.— The above 
changes are accentuated by processes going on in the psyche. The 
child observes changes in her form and outline, observes external 
evidences of puberty, is subject to psychic stimuli, all of which 
affect the general nervous system. The degree and character of 
the influence exerted from the genitalia depend on the resistance 
of the nervous system, or on the temperament, hereditary consti- 
tution, education, and training. In children of families charac- 
terized by irritable excitability, in children in large cities, in 
children who work hard at school and high school, in children 
who early become cognizant of genito-sexual matters, in girls 
whose thoughts have been directed into abnormal channels by 
other children, all the changes occurring at the establishment of 
menstruation work with greater intensity and with manifold varia- 
tions. 

The immediate surroundings in which a young girl lives dur- 
ing her sexual development all have an influence. In the families 
of working-girls there is often too much physical labor, poor 
nutrition, work involving the use of the lower extremities, and 
often early sexual stimulation. In the country, on the other 
hand, the girls develop gradually and normally in surround- 
ings which give them fresh air, nourishing food, and bring 
them less into contact with conditions which produce sexual sug- 
gestion. In the city, again, association with older girls, associa- 
tion with the opposite sex, early entrance into social life, attend- 
ance at theatre, and the reading of general literature all have a bad 
sexual effect. All these, added to the knowledge of development 
and the establishment of the menstrual function, and the char- 
acter of the child's associations, determine the degree to which the 
hazy and indefinite "sexual instinct" follows a normal or excitable 
course,. Psychologic reaction to the " sexual instinct" at puberty 
evidences itself in many ways, all of which represent the need of 
expressing objectively the newly developed inner feeling. Religion 
and poetry are often the fields in which these longings are expressed. 
Young girls at puberty often give themselves up to enthusiastic 
admiration and adoration of ideals or concrete factors. The 
mind of adolescent girls is often occupied with thoughts which 
concern the objects of their affection. Exciting or immodest 



ASSOCIATED NERVOUS CONDITIONS 279 

literature and plays and the influence of sophisticated associates 
may start the indefinite, hazy, sexual inclination into a flame 
(Kisch). 

The Influence of Heredity. — The surroundings and training 
of the young girl have much to do with the way in which ovarian 
activity acts on the brain and nervous system. Heredity, however, 
plays an all-important part. 

A neuron, feebly endowed and without enduring qualities, is 
acted on with marked force by the conditions which reduce the 
general health. There then results a neuropathic disposition 
of the nervous organism which yields readily to severe strains 
and unusual influences. As Mendel says, a hereditary basis 
generates a predisposition to mental and nervous irritability and 
produces certain peculiar natures which deviate in thought and 
action from the average. These individuals with difficulty pre- 
serve their nervous equilibrium. Many psychic peculiarities arise 
from imitation in childhood, through vicious environment or by 
faulty training. The cramming in schools plays an essential 
part only if it forces slightly gifted children to unusual work and 
puts too great a strain on a weak general system. 

The hereditary taint, especially if connected with anemia and 
onanism and infectious diseases, may form a basis on which ner- 
vous and mental alterations may develop between the twelfth and 
twentieth years, which alterations are most frequently of a hysterical 
nature. If children tainted hereditarily are exposed to mental 
exertion not corresponding to their powers, and if there is com- 
bined with this onanism and great loss of blood at the beginning of 
the menstrual epoch, a psychosis may develop at the time of puberty. 

In the simple forms the disease is generally characterized by 
hypochondriac depression, and the girls feel themselves incapable 
of labor. These children are backward at school, sleepless, 
suffer from headaches, cardiac palpitation, and loss of appetite. 
They become refractory, disobedient, and disrespectful. These 
children are considered as lazy and ill-bred and the real condition 
is not recognized as pathologic. 

The establishment of menstruation is especially liable to excite 
nervous disturbance in hereditarily neurasthenic and psychopathic 
girls. 



280 MEDICAL GYNECOLOGY 

Neuroses at Puberty. — Neuroses and psychoses may develop 
during puberty in such girls or in individuals living under un- 
satisfactory conditions of life or under the pressure of constant 
disturbing or irritating influences. Among these Kisch mentions 
hemicrania, precordial anxiety, epilepsy, imperative concepts, 
kleptomania, pyromania, and various phobias and anxieties. 

The establishment of menstruation sometimes acts well and im- 
proves the nervous condition; especially so is this the case in 
well-developed girls who have not yet menstruated. 

The inherited psychopathic tendency shows itself especially at 
puberty. The neurotic predisposition, kept in the background by 
the resistance and energy of childhood, takes on a sudden and 
stormy evolution through the menstrual stimulation and its asso- 
ciated constitutional involvement. Most frequently mania and 
melancholia are noted; then the morbid ideas associated with 
imperative concepts and the moral psychoses of puberty, according 
to Kisch. Hysteria often develops at the time of the establishment 
of menstruation. Commonly the first hysterical attack occurs in 
association with the first menstruation; or else the first menstrua- 
tion brings back a previously existing but vanished hysteria. It 
is generally of mild form, consisting of attacks of laughter and 
tears, globus hystericus, and clavus hystericus. Hysteria major 
rarely occurs during puberty. 

Nearly one-half of the cases of hysteria develop between the 
fifteenth and twentieth years of age. The frequency of hysteria 
diminishes rapidly after the twenty-fifth year. Bernutz says 
that one-half of the cases of hysteria in women evidence themselves 
shortly before or at the first establishment of menstruation. Amen- 
orrhea and dysmenorrhea seem to stimulate the development of 
this nervous condition. Less frequently it is of the hystero- 
epileptic type. Associated with this condition are commonly 
so-called nervous moods, weakness of will, nervous instability, and 
functional anesthesias, convulsions, and paralyses. 

At the time of puberty there is a tendency in young girls of 
neuropathic heredity to epilepsy; it occurs suddenly with the first 
menstruation, and is generally then considered as a fainting fit 
due to the menstruation, but these attacks recur at each menstrua- 



< 

/ 



ASSOCIATED NERVOUS CONDITIONS 281 

tion, and most of these attacks of fainting in association with 
menstruation prove to be epilepsy. 

Among other conditions developing at puberty are migraine and 
chorea minor. Migraine often first begins in young girls entering 
puberty between the thirteenth and fourteenth years. Chorea 
minor, which is a functional disturbance in the motor area of the 
nervous system, is observed during the period preceding and 
comprising puberty, and is to be brought into relation to the changes 
occurring during this period of body development, especially in 
girls. 

NERVOUS SYMPTOMS IN CHLOROSIS 

Among the symptoms of chlorosis are " irritable heart, dyspepsia, 
and constipation, due to atony and passive dilatation of the sto- 
mach and intestines. There is easy exhaustion and fatigue of the 
skeletal muscles. There is a general sense of languor and lassi- 
tude. There is a great variety of spinal aches. Reflected neural- 
gias result from pressure on the spinal roots because the vertebrae 
are not kept in normal position by the weakened muscles" 
(Thomson). 

In chlorosis there is often associated a poor development of the 
genitalia. The pelvis in a certain proportion of cases is of the 
child's type; in others there is a poor development of the external 
genitalia, or a uterus infantilis, small ovaries, poorly developed 
breasts, etc. Seventy-four per cent, have failures of genital 
development of one form or another. Among non-chlorotics these 
conditions are found in only 24 per cent. Menstruation is, as a 
rule, disturbed. During the chlorosis there is very frequently 
absolute or relative amenorrhea. Those affected with monor- 
rhagia always show a decided change in the mucosa. In all, 77 
per cent, present a weakening of the menstrual function. 

Chlorosis is often hereditary, and occurs exclusively in girls, 
most frequently during the years of development and the years 
immediately following, and shows a tendency to recur. No 
theory with regard to chlorosis which leaves out of consideration 
its occurrence in girls only, at the time of or in connection with 
sexual development, deserves attention. It occurs most frequently 
between the fourteenth and twentieth years. According to Nie- 



282 MEDICAL GYNECOLOGY 

meyer, such cases as occur for the first time after the twenty-fourth 
year are almost never chlorosis. 

Thomson believes the inference to be clear "that chlorosis is 
in some way related to the function of ovulation, and the problem 
is to find what this relation is." 

A justification for the statement that chlorosis is due to dimin- 
ished ovarian secretion is furnished by the effects of ovarian 
therapy in these cases. It may be considered that in chlorosis, 
with a failure of proper stimulation of the uterus and its lining, a 
diminished menstruation prevents thereby an excretion through 
the menstrual blood of toxins produced at puberty. There may 
likewise, at this stage, be a certain antagonism between the thyroid 
gland and the ovary. Since many of the cases of chlorosis present 
symptoms not unlike those found in Basedow's disease, it is possible 
that a too greatly diminished secretion of ovarian extract causes a 
relatively increased amount of thyroid extract to circulate in the 
blood. For this speak the good results obtained by Seeligman 
and others in the treatment of typical morbus Basedowi with 
ovarin. The ovarian secretion is a stimulator of blood-formation, 
and causes a congestion of the genital organs. Thyroid extract, 
on the contrary, causes anemia of the genital organs, as is seen in 
the good results obtained by the treatment of uterine fibroids with 
thyroid extract. It is possible that those chlorotic patients who 
take on fat have not alone a diminution in the function of the 
ovary, but likewise a diminution in the function of the thyroid, 
while those suffering with the milder symptoms of morbus Base- 
dowi have, with a diminished secretion from the ovary, a relative 
over- secretion on the part of the thyroid. 



NERVOUS SYMPTOMS DURING MENSTRUATION 

The ovarian secretion produces every twenty-eight days a pel- 
vic congestion, which is relieved, if no impregnated ovum is present 
in the tube or uterus, by a flow of blood from the uterine lining 
known as menstruation. Associated with this local congestion 
is a general congestion in the entire body, especially located in the 
various mucous membranes. This general congestion has natur- 
ally an irritating influence, and is more apt to increase any annoy- 



ASSOCIATED NERVOUS CONDITIONS 283 

ance existing in the sensitive portions of the body. It increases 
the tendency to skin affections; and it increases the tendency to 
headaches and to neuralgias, and it increases any tendency to 
excitability, mild hysterical attacks, etc. These results are due 
to the constitutional processes which are associated with menstrua- 
tion and to the coexisting stimulation of the thyroid. 

Schauta gives us the symptoms noted in other organs than the 
uterus during menstruation, and especially in dysmenorrhea — 
feeling of heat, cold feet, vomiting, pain in the abdomen, loss of 
appetite, frequency of urination, dyspepsia, headache, hysterical 
manifestations, etc. Among the latter there is conjunctival 
anesthesia, hyperesthesia of certain points in the abdomen, singul- 
tus, spasm of the glottis, epileptiform attacks. Recurrences of 
dysmenorrheic pain are sometimes enough to shatter the nervous 
system and to provoke neuroses and psychoses. One of the most 
important sequelae of dysmenorrhea is headache, diffuse or of the 
form of hemicrania. Long- existing dysmenorrhea increases the 
tendency to the development of hysterical attacks. 

Amenorrhea. — If the ovaries are functionating, there often occur 
strong painful molimina menstrualia, which appear at the time of the 
expected but omitted bleeding. If there is absence of or markedly 
diminished ovarian function, there are no local annoyances. 
Amenorrhea may be associated with mental irritability, skin 
hyperesthesia, and various neuralgias and true psychoses. Amenor- 
rhea is often due to chlorosis, obesity, diabetes, and the abuse of 
alcohol and morphin, myxedema, and Basedow's disease. With 
these, of course, there exist the special nervous symptoms of the 
particular disease. 

Menorrhagia and Metrorrhagia.— If of great amount, either 
produces anemia. Patients are pale, incapable of activity, suffer 
readily from palpitation of the heart and fainting attacks, and are 
prone to degenerative processes in the heart muscle. 



ONANISM AS A CAUSE OF NERVOUS SYMPTOMS 

Onanism must be reckoned among the factors which predis- 
pose to increased irritability of the nervous centers. Koblanck 
found that of thirty cases of amenorrhea all confessed to mas- 



284 MEDICAL GYNECOLOGY 

turbation. Sixteen were married, and of these eight had borne 
children. The duration of amenorrhea varied from three months 
to several years. The symptoms were headache, dyspnea, and 
sleeplessness. The tendency to masturbation was especially 
strong at the time for menstruation. Attracted by the observation 
of Fleiss, Koblanck noted that many disturbances in the menstrual 
function, especially dysmenorrhea, are associated with circum- 
scribed swellings of certain nasal areas, namely, the anterior end 
of the lower turbinated bone and the directly opposite area of the 
nasal septum. He found that this was produced by strong sexual 
excitement unaccompanied by the relief resulting from physiologic 
completion of this state. For the treatment of amenorrhea, the 
stopping of the masturbation is a necessary factor. 

Koblanck observed that menorrhagia was often due to masturba- 
tion and to disturbances of a sexual character. Sixteen women 
with menorrhagia and metrorrhagia acknowledged abnormal 
sexual processes (especially interference with natural completion, 
due to a desire to prevent conception). The symptoms improved 
with the regulation of the sexual relation. These disturbances 
resulting through masturbation in the non-gravid open to him the 
question as to the possibility of evil results in the pregnant. He 
observed that unconscious eclamptics often practised onanism. 
He found in these eclamptics nasal swellings and enlargement of 
the thyroid lobes. He questioned twenty women who recovered 
from eclampsia, and many confessed to onanism in pregnancy. 
The desire to masturbate was observed in those who practised 
onanism before marriage as well as in those who had not made use 
of this practice before. 

In the opinion of some, masturbation does not act injuriously 
through mechanical irritation, but does act injuriously psychically. 
It may be said, however, that masturbation does produce congestion 
which is not relieved and regulated by the omitted orgasm. 
What is the relation of masturbation to anomalies of menstrua- 
tion and to psychic disturbances? If masturbation produces 
amenorrhea or disturbances of menstruation, we may infer a 
consequent alteration in ovarian secretion and its elimination. If 
we grant that masturbation has an effect on menstruation, we may 
safely add psychic phenomena, to the list of resulting evils. On 



ASSOCIATED NERVOUS CONDITIONS 285 

the other hand, it may be asked whether masturbation is entirely 
a cause or a symptom, and whether onanism and amenorrhea are 
not often evidences of defective ovarian action and secretion and 
defective mental and nervous organization. At any rate, we may 
grant that increased nervous irritability is the result of onanism. 
More especially would this be true in the case of the pregnant 
woman. Onanie may be stimulated in very young children as a 
result of local irritation. In adolescent girls about the time of pu- 
berty there results, through changes produced by sexual instinct, by 
knowledge, and by discussion of the question, an indefinite attrac- 
tion toward the genitalia which leads to onanie, which attraction 
is more intense and occurs earlier if the girl is hereditarily psycho- 
pathic. The local menstrual congestion plays a role in onanie 
by producing hyperesthesia in the genitalia. The patients are 
pale, with tired expression of the face, dark rings about the eyes, 
dreamy in their movements, remain long in bed, etc. 

A tendency to onanism is produced either from the periphery or 
from the centrum. The two forms are, first, peripheral and 
mechanical; second, psychic or thought onanie. In the peripheral 
form, onanie is produced by friction of the clitoris and vagina 
brought about in numerous ways. In the second form the orgasm 
is produced by central stimulation, by imagination and fantasy of 
a sexual, lascivious nature. In older individuals the sequelae 
are fluor, menorrhagia, pain in one or both ovaries, pallor, hys- 
terical symptoms. A neuropathic predisposition often plays a 
causal role. When this neuropathic tendency is absent, onanie 
only by excessive practice causes marked nervous disturbances. 
Lowenfeld says that the nervous annoyances resulting from onanie 
in a certain number of cases follow the sexual form of myel- 
asthenia characterized by backache, hyperesthesia and paresthesia 
of the form of ovarie and pruritus vulvae, increased frequency of 
micturition, coccygodynia, a feeling of weakness and cold in the 
legs and the occurrence of pollutions. In the course of time there 
occur symptoms of cerebral and visceral neurasthenia, such as 
headache, sleeplessness, palpitation of the heart, nervous dyspeptic 
symptoms, so that more or less the condition rises to the dignity 
of a general neurasthenia. In addition, various hysterical symp- 
toms may be added to the neurasthenic annoyances. 



286 MEDICAL GYNECOLOGY 

NERVOUS ANNOYANCES IN PREGNANCY 

The congestion occurring in menstruation is, of course, carried 
on continually through the period of pregnancy, and while there 
is no absolute rule in the matter, it is quite sufficient to increase 
the same tendency to annoyances as is observed in the congestion 
of menstruation. In addition to this, we must remember that the 
placental secretion is an added element present in the blood of 
the mother, and that it may, and does in numerous cases, add 
further annoying symptoms to the expected physical discomforts 
which generally accompany that state. The feeling of nausea, 
the morning vomiting, the emesis, and. the hyperemesis are all 
annoying factors associated with pregnancy, especially in the 
early months, and are in all probability due to or aggravated by the 
action of placental secretion. 

Nervousness, nervous annoyances resembling "hysterical symp- 
toms," chorea, etc., are recognized possibilities in the course 
of pregnancy. It is evident to every one that women with 
nervous symptoms are not infrequently made worse by the meta- 
bolic changes and the added placental secretion associated with 
gravidity. That women who are pregnant are liable, for emo- 
tional or other reasons, to the same general nervous annoy- 
ances as non-pregnant women are, is of course not to be con- 
troverted. On the other hand, many women feel better during, 
and especially after, a pregnancy than they did before. Even 
in pregnancy symptoms resembling hysteria or neurasthenia 
occur in women who formerly showed no evidence of these condi- 
tions, and it is quite possible that alterations in the relation between 
the ovary, the thyroid, and the placental secretion are responsible 
for these changes. 

The proneness of women to gastro-intestinal derangement in 
connection with menstruation, pregnancy, and the menopause is 
well known. In each of these conditions digestive disorders 
frequently occur, with nervous accompaniments not unlike in 
nature to the incipient symptoms of Graves' disease. 

We need only refer to the experiments which have been made 
on pregnant rabbits, showing that in them the nervous system is 
much more excitable than in rabbits not pregnant. The same 



ASSOCIATED NERVOUS CONDITIONS 287 

sensitiveness of the nervous system is beyond doubt present at 
menstruation, and most assuredly is this the case during pregnancy. 
It needs only casual mention to recall the fact that even today 
many consider the nausea and emesis of pregnancy to be due to 
hysteria, and that some observers have noted the stigmata of hys- 
teria in such cases. We here again repeat that, while the condition 
of pregnancy and its associated metabolic. changes naturally aggra- 
vate nervous conditions, the nausea and vomiting of pregnancy are 
due to metabolic changes occurring in that state, and that among 
the causal factors is the irritating placental secretion. 



THE RELATION OF PTOSES TO NEURASTHENIC SYMPTOMS 

A large proportion of displacements of the uterus and adnexa, 
of chronic congestion and venous stasis in the pelvis, are associated 
with " reflex" and constitutional symptoms. Not infrequently 
ren mobilis, gastroptosis, and enteroptosis are found coexisting. 
These patients often possess a flabbiness and lack of elasticity 
which is by no means the result of the gynecologic condition, so 
that we are compelled to consider the latter as part oj a general 
state. From the gynecologic standpoint we name this local condi- 
tion hysteroptosis. In addition to a local genital subinvolution, 
there is often present a general constitutional subinvolution, that 
is, a failure after labor in the return to the normal on the part of 
the various intra-abdominal ligaments, of the abdominal muscles, 
and of the general elastic and circulatory apparatus. Many of the 
symptoms due to such conditions in women are erroneously attri- 
buted to uterine versions and flexions, and to minor genital pelvic 
changes acting through reflex paths, and also to hysteria or neuras- 
thenia. 

A frequent obstacle in the proper care of these cases is the 
firm belief on the part of many patients that a gynecologic trouble 
is solely responsible for their general nervous condition. It is 
certain that many women suffering from abdominal and pelvic 
ptoses are considered to be hysterical or neurasthenic or nervous. 
The symptoms of splanchnoptosis (Glenard) are: (i) debility and 
lassitude; (2) sensations of uneasiness, weight, dragging, craving, 
emptiness, etc., in the abdomen; (3) symptoms of dyspepsia; 



288 MEDICAL GYNECOLOGY 

(4) nervous symptoms. The relation formerly considered to 
exist between ren mobilis and the general nervous condition of the 
patient is now recognized to really exist between a combination of 
abdominal ptoses and a general state. It cannot be said that 
abdominal and pelvic ptoses cause neurasthenia. It may be more 
justly said that neurasthenic women are prone to abdominal 
ptoses; that Glenard's disease and neurasthenia are sometimes 
combined. It can be said, however, that abdominal ptoses and 
pelvic ptoses are often productive of "neurasthenic symptoms," 
and that many patients suffering from abdominal and pelvic 
ptoses do have symptoms which, especially if the cause be not 
recognized, can readily lead to a diagnosis of hysteria or neuras- 
thenia. One has only to consider the relief afforded by abdominal 
supports and by hydrotherapy as well as by local therapy, to see 
the relation which these ptoses bear to symptoms often attributed 
to pelvic conditions alone or to neurasthenia. 

Abrams has described a special form of nervous weakness desig- 
nated as "splanchnic neurasthenia," which is characterized by 
paroxysms of depression of varying duration, and which are speci- 
fied popularly as "the blues." Splanchnic neurasthenia is charac- 
terized by attacks of depression which come on spontaneously 
without apparent cause and depart as mysteriously as they came. 
Abrams believes an attack of the blues to be naught else but an 
acute neurasthenia, or a periodic exacerbation of chronic neurasthe- 
nia. He holds that many cases of neurasthenia have an abdom- 
inal origin, and that the neurasthenia may be referred to a defect 
in the nerve apparatus which controls the supply of blood in 
the abdominal cavity, and that this condition is eradicable by sim- 
ple methods. He finds a large number of gastric and intestinal 
affections, with bizarre and protean symptoms, designated as 
gastric and intestinal neuroses, which in reality owe their genesis 
to the congestion of the intra-abdominal veins. The greater 
the intra-abdominal tension, the less blood will be contained 
in the abdominal veins. This tension is largely dependent 
on the tone or tension of the abdominal muscles. Therefore, 
nervous exhaustion is a frequent cause of diminished tone of the 
abdominal muscles, which in turn diminishes intra-abdominal 
tension and conduces to blood stagnation in the veins of the abdo- 



ASSOCIATED NERVOUS CONDITIONS 289 

men. The toxic products of digestion, which are normally re- 
moved by an unimpeded circulation, have a specifically poisonous 
effect on the sympathetic system, a fact which is evident, owing 
to the frequent occurrence of depression, prostration, and nervous 
symptoms in nearly all disorders of the alimentary canal. In 
his opinion the entire question of splanchnic neurasthenia is 
one of abdominal plethora, dependent on a variety of causes, 
notably diminished intra-abdominal tension, insufficient lung 
development, a defective vasomotor apparatus. Splanchnic neur- 
asthenia is one of the forms of neurasthenia amenable to per- 
manent cure, by measures having for their object the relief of 
abdominal venous congestion. 

DIMINISHED EXCRETION OF UREA 

The amount of urea output in women is often below the normal. 
In such states various "nervous symptoms" are often present. 
W. H. Thomson mentions among the symptoms of deficient urea 
excretion headaches, mental depression, severe neuralgias, con- 
stantly shifting from one part of the body to the other, all kinds of 
paresthesias, somnolence alternating with insomnia, and a sense 
of general prostration, especially in the morning, and also in some 
instances polyuria. Thomson says that these cases are generally 
diagnosed as hysteria of neurasthenia. 

HYSTERIA 

"Hysterical Symptoms.' ' — Gowers says that the manifesta- 
tions of hysteria may be divided into a mental state and into motor 
and other symptoms. There is defective power of will, imperfect 
self-control, inability to resist the impulses of inclination, irritabil- 
ity of temper, undue sensitiveness to annoyances, whereby trifling 
cares and vexations become grave troubles. Self-consciousness 
dominates the patient's thoughts and even her actions. Laughter 
and tears come readily. There is the globus hystericus. Such 
patients are characterized by variable moods, by emotional, excit- 
able temperament. The patients are easily exalted and easily 
depressed; tears and laughter follow on insufficient cause. There 
is too ready susceptibility to passing impressions of the moment. 
19 



290 MEDICAL GYNECOLOGY 

There is increased sensitiveness, hysterical tenderness, and neural- 
gic pain. There is hyperesthesia or lessened sensibility, often in 
the legs, with motor weakness. There are areas of anesthesia. 
The ovarian region is often sensitive, as is also the spine; there 
are palpitations, flushings of the face, vasomotor spasm, fainting, 
and vomiting. 

The stigmata of hysteria are corneal and pharyngeal insensi- 
bility, areas of skin anesthesia and hyperesthesia, concentric 
contraction of the visual fields, hysterogenic zones, convulsions. 
There is tenderness, either superficial or deep. The patient is 
generally aware of it, in contradistinction to anesthesia. There 
is tenderness often in the ovarian and inframammary regions, in 
the upper abdomen and along the spine. Patients suffer from 
dyspepsia, gastric pain, flatulence, obstinate diarrhea, diarrhea 
after eating, rapid action of the heart on the slightest emotion, 
with or without subjective sensation of palpitation. 

Tremor may be present, which is fine and rapid, like that in 
alcoholism or in Graves' disease. There may be tachycardia 
with or without palpitation. There may be a persistent rapid 
pulse. The differential diagnosis must be made from the irregular 
forms of Graves' disease. 

There is often irritability of the bladder, the patient sometimes 
passing water twenty to thirty times a day. 

"The motor, vasomotor, sensory, and circulatory symptoms are 
related to emotional disturbances, alike in their commencement, 
course, and manifestation. They frequently follow mental shock, 
or are gradually evolved under the influence of more persistent 
emotional disturbances, and may be intensified from time to time 
under the same influence. Another characteristic is the mutability 
of symptoms, whereby grave troubles of one kind cease and give 
way to other symptoms, such as cannot result from the same 
organic causes as the first." 

I accept Osier's view that hysteria is often diagnosed where there 
is really neurasthenia, and that in the absence of hysterical parox- 
ysms, of crises, and of those marked emotional and intellectual 
characteristics of the hysterical individual, the diagnosis of hysteria 
should not be made. The tendency to hysteria is primarily an 
evolutionary defect. A marked constitutional hyperemia at every 



ASSOCIATED NERVOUS CONDITIONS 29 1 

menstruation, severe dysmenorrhea, and long-continued pelvic pain 
are among the exciting factors which may bring on hysterical 
manifestations in predisposed individuals. Likewise, the preying 
consciousness of an abnormal pelvic condition, though in reality 
giving rise to no symptoms, may act as a psychic irritant. How- 
ever, the causal relation of pelvic diseases to hysteria has been 
grossly exaggerated. 

NEURASTHENIA 

Nervous persons, says Clarke, are perhaps best distinguished 
from those not so disposed by a difference in physical reaction to 
external agencies, by a tendency to exhibit psychic disturbances 
on what appear to be inadequate causes. 

Many persons possess a congenital peculiarity of nerve function, 
for which they may seek medical advice, but which is not really 
morbid. Such is the persistence of the " shyness" of early life, 
or a tendency, lifelong, to look on the darker side of things, or the 
vasomotor activity which causes so many persons, all through the 
first half of their lives, to blush on the least emotion and flush under 
every favorable physical influence. In many cases of neurasthenia 
the condition is distinctly "constitutional"; that is, the defect in 
the nervous system is inherent in the individual, and a similar 
ancestral tendency can often be traced. It dates from childhood 
in some; in others it comes on after puberty or in early adult life, 
without any discoverable cause. Of the latter a large proportion 
are females, who are unable to bear even the average strain of life 
and break down in various ways. They may be raised to a little 
higher level of nervous health, but cannot be made really strong 
(Gowers). 

Clarke defines neurasthenia as "a nervous disorder without any 
known alteration in organic structure, characterized by a persis- 
tent state of fatigue, and hence of weakness of the central nervous 
system, in the absence of the causes which normally are adequate 
to induce such fatigue, and at the same time by a loss of control on 
the part of the higher nervous centers, and hence by an excessive 
reaction in certain directions to slight irritations." 

The cardinal symptoms, recurring in different combinations, 
and called by Charcot the stigmata of neurasthenia, are pains 



292 MEDICAL GYNECOLOGY 

in the head, dizziness and vertigo, inability for mental work, 
various disorders of sleep, irritability of temper, weakness and 
tremor of the limbs, pains in the back, palpitation, certain forms 
of dyspepsia, sexual weakness, worry over trifles, loss of will- 
power, indecision, hesitation, insomnia. There may be tremor, 
which is fine, like that of Graves' disease, or fine twitchings of the 
tongue and eyelids. Tenderness and pain are felt over the spine. 
The pulse in many cases is between 80 and 90, occasionally 100 
to 120. It is hard to make the diagnosis from the milder forms oj 
Graves 7 disease. Attacks of tachycardia occur after excitement or 
mental strain. There is dyspepsia or some form of gastro- intestinal 
disorder; flatulence or diarrhea or constipation. Glenard's dis- 
ease is not often found. Irritability of the bladder and oxaluria 
are rather frequent. Weakness of the legs is common. There is 
often tremor in the legs, with a feeling of "giving way" at the 
knees. The patients have anxieties and fears. 

Fatigue may be produced with undue readiness by muscular 
exertion and by mental effort. Muscular strength is only lessened 
in the severe degrees of nervous weakness, but the power of sus- 
tained effort is generally reduced. Fatigue is not only sooner felt, 
but is often a more unpleasant sensation than the fatigue of health, 
and whatever pain or discomfort to which the sufferer is liable is apt 
to be induced. Often talking may cause a feeling of weariness and 
cephalic sensations to which the patient is liable. Many of 
the sufferers habitually talk in a low voice, as if every sentence 
involved an exertion almost beyond their strength. A sense of 
muscular inertia and powerlessness is very frequent, especially 
in the earlier part of the day, when there is no real lack of strength. 
The least effort, indeed, for any exertion may seem beyond 
their power. The frequency with which the gynecologist is con- 
fronted with symptoms of neurasthenia makes it imperative that 
he have a clear conception of the relationship of these nervous 
phenomena to the conditions which he is called upon to treat. 
It takes more than a few "neurasthenic symptoms" to constitute 
the clinical entity neurasthenia. Anemia, onanism, pregnancy, 
the puerperium, lactation, the climacterium, are contributing 
factors in producing neurasthenic symptoms. Unless associated 
with great continued loss of blood, or with long-continued pain, 



ASSOCIATED NERVOUS CONDITIONS 293 

I do not believe that pelvic diseases, viewed as local conditions, 
are responsible for the development of the essential neurosis, 
neurasthenia. 

REFLEX NEUROSES 

A subject which is of greatest interest in gynecology is the ques- 
tion of reflex neuroses. 

There is a tendency to refer many or all of the nervous symptoms, 
especially in married women, to local disturbances in the genital 
tract. Prolapsed ovaries, cystic ovaries, lacerated cervices, ante- 
flexions, and especially retroversions and retroflexions, are accepted 
as the etiologic causes, through reflex channels, of many and nume- 
rous nervous symptoms. We find many observers who attribute 
to reflex channels the etiology of symptoms, while others consider 
the association of pelvic lesions and general nervous symptoms 
to be a coincidence, while still others consider the local lesions as 
the exciting cause in predisposed individuals. 

Numerous women bear children, work hard, and never have 
physical or nervous annoyances at any period of their lives. We 
know others who, for causes mainly inflammatory and circulatory, 
have constant physical pelvic disturbances without nervous mani- 
festations. We see many women who, combined with these 
local pelvic disturbances, evince nervous phenomena of greater 
or lesser variation. Another large class is formed of those who, 
without local tangible pelvic changes, have nervous annoyances 
of a greater or lesser degree. 

W. H. Freund speaks of the "predisposition of sex," and says 
that we must seek in local processes, in disturbances of nutrition, 
and in the variations of metabolism the elements productive of 
nervous annoyances. General disturbances of nutrition, as they 
occur in women's diseases, furnish a high degree of predisposition. 
Chlorosis and anemia are factors of importance. Menstruation, 
labor, subinvolution, loss of blood and secretions, poor digestion 
following severe diseases, cachexia, and early senescence are also 
to be mentioned. "All these factors may produce nervous annoy- 
ances or serve as the agents predisposing to neurasthenic and hys- 
terical symptoms." 

Freund recognizes a strong predisposition in these mentioned 



294 MEDICAL GYNECOLOGY 

changes, and in direct injuries, in inflammatory changes and 
infections of the genitalia, in sexual overexcitement, in atony of 
the pelvic and abdominal organs. Of importance, in addition, 
is also hereditary tendency, congenital irritability of the nervous 
system, unsuitable education, and psychic changes. 

The diagnosis of pelvic abnormalities as the cause of pain 
elsewhere produced through reflex is to be made with care. Many 
general conditions are to be looked for. A thorough exam- 
ination often shows hysteroptosis, enteroptosis, gastroenter- 
optosis, ren mobilis, etc., to be responsible for many annoyances 
attributed to uterine malpositions, to cervical lacerations, etc. 
Many women have pelvic pain due to unrecognized parametritis, 
to slight degrees of salpingitis, peri-oophoritis, etc. Many suffer 
from rheumatism and auto-intoxication. Headaches and neuralgic 
pains are frequently due also to nodules and deposits in various 
parts of the body which may be removed, to the vast benefit of 
the patient, by persistent massage. Many suffer from backache 
because of enteroptosis or hysteroptosis, or parametritis or pelvic 
congestion. Women often have annoying symptoms, which depend 
on a faulty and diminished excretion of urea or are due to lithemia. 
This extremely important condition in women should always be 
looked for. Further, a diminished excretion of urea is productive 
of many nervous symptoms. 

I do not believe that those anatomic changes in structure which 
do not cause pain can be considered as factors by way of reflex in 
the causation or accentuation of nervous symptoms. Attention 
is due cases with actual lesions of importance in the genital tract. 
We must grant that inflammatory changes of minor or severe degree 
which cause marked or protracted pain can readily wear down the 
nervous system. 

"It is not always easy to decide whether, in conditions occurring 
at the same time in different parts of the body, there exists an 
accidental coexistence or a causal relation. In general, one 
thinks first of a connection by means of the cerebrospinal or 
sympathetic nerves," in spite of the fact that to these, as W. H. 
Freund says, there falls an inferior role. The relation of the 
internal secretions to the nervous system is far more important. 

He, however, believes that irritation of the nerves of the genital 



ASSOCIATED NERVOUS CONDITIONS 295 

organs by palpable nodules, sclerosing connective tissue, an inflam- 
matory focus, a hemorrhage, give rise to reflex symptoms. The 
paths through which such lesions act reflexly are the spinal cord 
and the cerebrospinal fibers, but especially the sympatheticus, 
by which the genital system is richly supplied. In parametritis 
chronica atrophicans, severe perineuritis and neuritis of the 
nerve-supply situated in the broad ligament have been found. 
Freund considers this condition as an established basis of hysteria 
and says that where this condition is present hysteria is never 
absent. He defines hysteria as "that disease in which there is 
clearly noted, coming out from the diseased area, and also called 
forth by examination, reflex neuroses, which, according to their 
place of manifestation, must be called sympathetic, or spinal, or 
cerebral. To this neurosis, sooner or later, is added a psychic 
reaction, differing according to constitution, inheritance, and 
'bringing up.'" We see here a definition of reflex etiology not in 
keeping with the generally accepted understanding of hysteria pure 
and simple, a definition with which I do not agree. 

In the discussion of Freund's views the following opinions have 
been expressed. 

Brose says that in cases of severe hysteria he finds, in almost 
all of them, parametritis atrophicans. He makes the diagnosis 
through the stigmata of Charcot. One patient, with all the ob- 
jective and subjective symptoms of hysteria and hysterical delu- 
sions, had parametritis atrophicans. He fears that she will end 
in the insane asylum. In a second case he did a ventrofixation, 
and the local and hysterical symptoms disappeared, although for 
weeks after the operation the patient suffered from hysterical 
vomiting. There are many patients who have hysteria with 
objective symptoms, even after the correction of the displacements. 
The reflex neuroses of a retroflexion have, in his opinion, nothing 
to do with hysteria. Chronic adnexal troubles, without para- 
metritis atrophicans, do not cause hysteria. He believes chlorosis 
to be a cause of hysteria, and considers hysteria a secondary condi- 
tion, and not a true psychosis. 

Olshausen says that hysteria is a psychosis, and that reflex 
neuroses do not constitute hysteria. There are, however, certain 
local lesions which do cause this condition, and he mentions the 



296 MEDICAL GYNECOLOGY 

case of a girl twenty years old with severe hysteria and epileptiform 
attacks occurring every night at 8 o'clock. In spite of isolation 
and various attempts to deceive her as to the time of day, the attacks 
occurred regularly at the same hour, and he removed her ovaries and 
the patient became well. He believes that faulty training of wilful 
children, especially where the conduct of the child has been poorly 
controlled, is often the cause of hysteria appearing at puberty. 

Koblanck says that he sees many neurasthenias, but few hys- 
terias. He believes that sexual disturbances are a frequent cause 
of nervous conditions. 

Mackenrodt finds the most important cause of neuroses in the 
field of the sexual organs. He had a case like Olshausen's, which 
was cured by operation, and stated that Sanger made the same 
observation in many cases in the Leipsic Insane Asylum. Macken- 
rodt finds with Freund's disease many neurasthenic symptoms. 
The local condition acts for years, until a strong psychic irritation 
occurs and then a psychosis results. 

Shaeffer finds that retroflexion, combined with ren mobilis, 
enteroptosis, and loose abdominal walls, are closely related, etio- 
logically, to psychic conditions. In his opinion, all chronic gyneco- 
logic troubles, especially inflammatory, may give rise to hysteria. 

Lippmann says that hysteria is a disease of the central nervous 
system, which in predisposed cases can be started from various 
peripheral parts of the body, through various conditions in those 
parts, most frequently from the genital system, and sometimes from 
the ovaries. He refers to a case of hysteria in a girl who men- 
struated at twelve, with pain in the ovarian region. He mentions 
the fact that for the first year and a half of the disease the 
attacks followed a monthly type and then became general. She 
then developed fibrillary twitchings, temporary contractures, con- 
vulsions, and finally opisthotonos of long duration. She was 
operated on by Schroeder at the age of twenty-six. One ovary 
contained a dermoid, the other was cystic. The attacks stopped, 
and in four years she was well. 

Steffeck believes in various causations. He does not think 
that gynecologic troubles are the cause of hysteria, but holds that 
in the hysterically predisposed individual, through auto-suggestion 
or ecto- suggestion, there develops the idea that there is a definite area, 



ASSOCIATED NERVOUS CONDITIONS 297 

an injured spot, which produces the hysterical symptoms. Steffeck 
terms them, ij they are to be regarded as hysteria, " local or localized 
hysteria" He believes hysteria to be a true psychic disturbance, 
through inherited or acquired sensitiveness, as a result of which a 
pathologic reaction occurs, with the most varied injuries. He 
believes that faulty education, disturbances of adolescence, uncon- 
genial marital relationship, etc., are important points in the causa- 
tion of hysteria. 

Strassmann is very careful in the diagnosis of hysteria. He 
believes that nervous symptoms may be produced by abnormal 
sexual relations, not alone physical, but also mental — coitus inter- 
rupts, masturbation, marriage with impotents, and in women 
not happy in a sexual-ideal way in marriage, women who feel 
themselves neglected, etc. He does not accept Freund's etiology. 

Gottschalk says that not every hysterical symptom makes a 
hysteria, and he speaks of a reflex hysteria and of a central hysteria. 
Peripheral lesions may reflexly cause a hysterical picture, but 
these cases are far in the minority. He believes in the element 
of heredity, and when an irritating cause appears, a hysteria 
develops. Among the irritating causes are marriage with impo- 
tents, masturbation, and coitus interruptus. 

I believe that the views of Strassmann and Steffeck are the 
correct ones, and that they dispose, to a great extent, of reflex 
neuroses and bring us to a realization of the fact that incessant 
pain and mental perturbation act sometimes without injury and 
sometimes with injury, upon the nervous system of the female, 
according to the predisposition oj the patient. We can see here the 
great difference in opinion as to the etiologic relationship between 
gynecologic conditions and nervous symptoms. That most of 
the cases considered to belong under the head of hysteria are 
really "neurasthenic" is certainly true. We should not attribute 
to purely local pelvic conditions not associated with pain the 
causation of neurotic and psychic phenomena. . 

The reaction and mutual relation between physiologic functions 
and altered activity of the ovaries, on the one hand, and the general 
organism, on the other, must be considered. We not only need an 
anatomic knowledge of the genital system and its diseases, but 
must also observe the influence of genital and sexual development 



298 MEDICAL GYNECOLOGY 

on the general female organism. We must study the relation of 
normal and altered ovarian and thyroid activity on the psychic and 
physical characteristics of women. The first onset of menstruation, 
the period of complete development of the sexual organs, the ele- 
ments of sexual relation, conception, pregnancy, labor, puerperium, 
and the retrogressive changes involved in the climacterium and the 
cessation of menstruation cause physiologic processes and patho- 
logic changes in various organs and in the general nutritive con- 
dition; in the function of the heart and circulation, in the ovaries, 
nerves, skin, mind, digestion, and metabolism. 

Modern culture and social conditions have an unfavorable 
influence on the sexual organs of women, which finds its expression 
in the great frequency of gynecologic diseases. Faulty training 
and manner of life lead to violations of nature's laws, and to 
injuries in the genital sphere. Even before complete puberty 
the phantasy of young girls is directed to the sexual processes by 
improper books, by plays, by social intercourse with men and 
women whose conversation and bent of mind are not clean and 
wholesome. Exciting and depressing psychic influences pass 
out from the genital sphere. The growing girl recognizes at 
puberty the meaning of sex; the developing woman feels an 
attraction to sexual gratification. Though the desire for children 
varies in degree, the sadness of sterility is often a tragedy. The 
influence of maternity and pregnancy is of much psychic impor- 
tance. The period from puberty to marriage may be influenced too 
much by the awakened sexual inclination. Inactive life, improper 
nourishment, and the early use of alcoholic drinks influence the 
psyche during this period and tend toward the development of 
the neurasthenic state. Late marriage furnishes an individual 
too well informed in sexual matters, and often one weakened and 
nervous through sexual longings and stimulations (Kisch). Sexual 
intercourse, with the accompanying methods of preventing concep- 
tion, have a bad effect on the nervous system and the genitalia of 
women. Actual or relative impotency of the husband, failure to 
show kindness and consideration, are productive of neuroses. The 
congestive influence of the ovaries, and the relation of the ovaries 
to the thyroid, produce marked changes in the genitalia and the 
genital sphere. 



ASSOCIATED NERVOUS CONDITIONS 299 

ABERRANT BASEDOW'S DISEASE 

Among the symptoms of Basedow's disease are: tachycardia, 
palpitation, nervousness, weakness of the lower extremities, 
weakness of the voice, depression, changes of disposition, head- 
aches, vertigo, insomnia, well-known disorders of the stomach 
and intestines, itching, vesical irritability, all the symptoms intensi- 
fied in the morning, sensation of so-called inward trembling. 

Functional derangement of the nervous system occurs in Graves' 
disease with a greater variety in the individual symptoms than in 
any other complaint, not excepting hysteria. The nervousness 
has much the character of mental agitation, not unlike that accom- 
panying a sense of fright. With some it takes the form of pure 
depression of spirits, worse in the morning. McCallum says: 
" Early in the disease the patients feel themselves to be irritable 
and excitable. Their friends observe a change in disposition very 
different from that observed in the development of myxedema. 
Instead of becoming sluggish and apathetic, with all the mental 
faculties dulled, these patients are occasionally susceptible to every 
outward stimulus, and the mental reaction is a relatively intense 
one. In some respects this receptive and reactive state may 
resemble in a mild way that seen in the maniacal stage of the 
maniacal-depressive insanity. A feeling of anxiety dominates the 
mental state and the patient becomes the prey of groundless fears. 
Insomnia may be persistent, much to the exhaustion of the patient." 

Mobius says of Basedow's disease: "Beside the picture rich 
in symptoms stand the aberrant forms, in which often only some 
few symptoms are demonstrable, and probably the extent of these 
aberrant forms is much greater than is generally supposed." 

When the typical symptoms of exophthalmos, goiter, tachycardia, 
and tremor are present, a correct diagnosis is, of course, readily 
made. This grouping of typical symptoms is by no means always 
present. There are many cases of Basedow's disease without 
exophthalmos or without goiter, or without either. This point 
is important, because it facilitates a correct diagnosis of many 
cases of ill health, the true nature of which is often not suspected. 
These patients, as W. H. Thomson says, are rated as hysterical, 
neuralgic, neurasthenic, rheumatic, or dyspeptic. 



300 MEDICAL GYNECOLOGY 

" Recognition of the fact that Graves' disease may occur without 
exophthalmos and without goiter will result in the proper treat- 
ment of the numerous class who have Graves' disease only in an 
incipient or mild form, characterized by dyspeptic symptoms with 
headaches, neuralgias and nervousness, and persistent tachycar- 
dia" (Thomson). Yet even tachycardia is not always present. 

There is a marked resemblance existing between "hysterical 
symptoms" and "neurasthenic symptoms" and those symptoms 
belonging to mild or aberrant forms of Graves' disease. These 
conditions must be differentiated from the irregular forms of 
Graves' disease. It is certainly difficult to make this differentiation 
from the milder forms. In those cases of Basedow's disease in 
which the typical symptoms are absent it is more than probable 
that the diagnosis of hysteria or neurasthenia is frequently made. 



THE CLIMACTERIUM 

In the climacterium the woman recognizes her diminished sexual 
value. In the period of full development of genital life the 
sexual instinct expands, the instinct for conception and propa- 
gation rises to full heights, and after the period of cohabitation and 
activity there comes a period of rest, diminishing down to passive- 
ness. At the pre-climacteric period and in the beginning of the 
climacterium there is awakened desire and increase of the libido 
sexualis. Certain pathologic symptoms which appear at the period 
of the establishment of menstruation, and which diminish or dis- 
appear from the field during the period of regular sexual function 
(such as heart annoyances, dyspnea, psychic neuroses, chlorotic 
states, albuminuria, skin lesions, etc.), arise again to full force at the 
time of tKe climacterium. In fact, so certain is this condition, ac- 
cording to Kisch, that the character oj the climacterium may be 
fairly well predicated from the peaceful, the irregular, or the disturbed 
general condition which existed at the period of puberty and the estab- 
lishment of menstruation. 

Healthy women who lead a wholesome life, who are well nour- 
ished and free from distressing influences as girls, who practise 
normal sexual relations, possess a longer period of genital life 
than women in opposite conditions. It is a sign of decadence 



ASSOCIATED NERVOUS CONDITIONS 30I 

when the well-to-do classes evidence a short duration of the sexual 
life. Hygienic and ethical life is associated with lengthening of 
life as a whole, as well as with the lengthening of the sexual activity 
of woman. The failure of culture and ethics brings a shortening 
of the period of sexual power. This holds true for the individual, 
for the family, and for peoples. Healthy women whose sexual 
organs are functionating normally, who have borne several chil- 
dren, who have nursed them, usually have a longer duration of the 
menstrual function than those under contrary conditions. Weak, 
debilitated women have a shorter period of sexual life. Mental 
irregularities and annoyances occur as a result of the early dis- 
appearance of the menstrual function. Chronic inflammatory 
diseases of the uterus and adnexa shorten the length of the sexual 
life. 

Many patients with nervous symptoms come into the hands 
of the gynecologist at that period of life which closely approxi- 
mates the time of normal menopause or climacterium. Many 
of these patients are ceasing to menstruate, either gradually 
or suddenly, and attention is naturally directed to the possible 
arrival of the critical period known to the laity as the "change of 
life." When, however, patients of this kind are still menstruating, 
or are menstruating more profusely than usual, this possibility is 
not sufficiently considered. On the other hand, this is the period 
in which various conditions are prone to produce not so much 
hysterical as neurasthenic symptoms. In many instances the 
symptoms are not those of the supposedly typical climacterium, 
and for that reason a differential diagnosis is rarely attempted. 
It seems that we find at this period of life two classes of cases : 
Those which may be considered as excitable, and cases which may 
be considered as melancholic or depressed. Those of the excitable 
class conform more closely perhaps to the usual picture associated 
with the change of life. It must be noted that after castration the 
same division into two classes is observed: (i) the excitable, and 
(2) the depressed. In not all instances are the vasomotor symp- 
toms present, nor are palpitation and irritability always observed. 
It is certainly easy in the form associated with depression to make 
the diagnosis of neurasthenia or nervous prostration. Although 
at this period of life, and perhaps more so than at others, true 



302 MEDICAL GYNECOLOGY 

neurasthenia does occur, nevertheless many of these cases are 
probably such as are produced by a diminution of the ovarian 
function. The frequent development, in the predisposed, of a 
true psychosis at this period must not be forgotten. 

According to Fehling, the evidences which accompany a natural 
menopause are congestions, flushes, sweatings, which have a 
tendency to disappear after one-half to one year; they sometimes 
last for years. There may be superimposed palpitation, dizziness, 
stomach and intestinal annoyances, a feeling of flatulence and 
distention, neuralgia, especially costal, sleeplessness, an anxious 
feeling, mental unrest, nervous irritability. 

It is important again to mention the fact that cessation of the 
menses is generally considered an essential evidence of the climac- 
terium. This is not so. One of the important complications of the 
climacterium is great uterine bleeding, regular or irregular in its 
occurrence. With these bleedings the essential constitutional and 
nervous symptoms of the climacterium may be present, even if not 
in full force. Because of the presence of the bleedings, the fact 
that climacteric symptoms may nevertheless be present is generally 
overlooked, so strong is the idea that only a cessation of men- 
struation is proof of the onset of the climacterium. 

During the natural climacterium the annoying symptoms are 
generally worse in those patients in whom atrophic changes in the 
uterus occur rapidly, while they are less annoying if these changes 
go on slowly. The patients who have irregular and profuse bleed- 
ings often, but not always, suffer less from the annoying constitu- 
tional and nervous symptoms. 

Castration. — That the ovarian secretion is not always of essential 
importance is evidenced by the fact that a goodly proportion of 
women go through the menopause without noticeable disturbances, 
and that a large proportion of the operative cases have little or no 
annoyance. The same variation in degree, in intensity, and in 
the duration of symptoms as is observed in the natural climac- 
terium is likewise observed after surgical castration. The dis- 
turbances after operation are at first mainly of a vasomotor nature, 
and are accompanied by psychic unrest. 

According to Martin, the symptoms after castration are rushes 
of blood to the head, combined with a feeling of anxiety. There 



ASSOCIATED NERVOUS CONDITIONS 303 

is often added thereto palpitation, dizziness, tinnitus, sweating. 
These symptoms occur in various combinations, often repeated 
several times a day. Continuation of these conditions leads to 
a feeling of weakness, to headaches, sleeplessness, etc. The 
symptoms usually improve after two or three years, but sometimes 
continue for five or six years. These states result from absence 
of the ovarian secretion. 

Fehling says that psychic disease is seldom noted. The symp- 
toms are worse in women formerly neurasthenic or hysterical. 

After surgical castration, even in the severe cases, the body 
eventually becomes accustomed to the absence of the ovarian secre- 
tion, probably through atrophy of the thyroid. The fact that 
many cases have few or no symptoms at all shows that the same 
variations are observed after castration as are noted in the meno- 
pause occurring along normal lines. 

Glaevecke says that castration develops an artificial climacterium, 
which in all points resembles the natural, and the female enters 
through the castration prematurely into the climacteric stage. 
"Castration cuts deeper into the general organism of the female 
than does total extirpation, and we must rate the mutilating effect 
of the first higher than the latter. Very noticeable are the changes 
in the mental sphere, where we generally see a depression of 
temperament, which is often increased to marked melancholia, and 
in these cases may go on to a real psychosis." 

On the other hand, Pfister claims that "the so-called mutilation 
(of castration) should not be rated so high, in that the influence 
which the female ovary exerts on the female organism is much 
overrated." 

Altherthum, too, says: "The complete removal of the ovaries 
does not at all produce the injurious results upon the mental and 
physical condition of the female that have been generally accepted." 

Abel says that "after removal of the uterus the ovaries enter 
into a more or less rapid atrophy, which causes, before the age 
limit of the natural climacterium, a complete disappearance of 
ovarian function. It is certain that after removal of the ovaries 
we see at once all the physiologic accompaniments and anatomic 
consequences of the climacterium developing in a relatively short 
time, more immediately and sharper than they generally take place 



304 MEDICAL GYNECOLOGY 

at the natural age limit. This is not so after the removal of the 
uterus alone. Here the transition is more natural and milder." 

The symptoms which may occur with either natural or artificial 
menopause are mainly the following: (1) Flushes, with or without 
reddening of the skin, frequently followed by a sensation of cold 
and sweating; (2) palpitation of the heart; (3) dizziness; (4) 
headaches; (5) sleeplessness; (6) disturbances of digestion; (7) 
irritability of temper; (8) tendency to either mental depression or 
excitement; (9) various " nervous" manifestations, especially 
psychic unrest; (10) psychic disturbances. 

According to Baruch and others, the annoyances after castration 
are most marked in nervous and hysterical women. They find it 
hard to distinguish in such patients between their former "nervous 
symptoms" and those which are due to the menopause. 

Mainzer, in the clinic of Landau, found that disturbances in the 
vasomotor system resulting after castration disappear upon the 
administration of ovarin; that disturbances at the natural climac- 
terium are benefited; that the results in primary or secondary 
amenorrhea are satisfactory, but that no effect is exerted upon 
general hysteria. 

Theory of the Climacterium. — In the study of the symptoms of 
the climacterium, either natural or artificial, I have long been accus- 
tomed to consider these cases as instances of what I have termed 
" relative Basedow's disease," because the symptoms resembled 
to a considerable degree the symptoms of Basedow's disease. 
The more important reason was the fact that I considered the 
symptoms of the climacteric cases to be due to relative hyper- 
thyroidism. Since Basedow's disease is considered to be due to 
hypersecretion of the thyroid, the term " relative Basedow's disease" 
seemed an apt one. 

It is certainly remarkable that the great majority of cases of 
well-defined or aberrant Basedow's disease are observed in women. 
To say that an affection of the ovaries is in a degree responsible 
for the genuine cases would be going rather far. The least that 
we can say, however, is that women are extremely prone to morbus 
Basedowi, probably because they possess ovaries. 

If cessation of ovarian secretion means unopposed thyroid ac- 
tivity, as seems evident from the symptoms occurring at menopause 



ASSOCIATED NERVOUS CONDITIONS 305 

and after castration, there is no reason why disturbances of function 
on the part of the ovaries may not be responsible for forms of "rela- 
tive hyperthyroidism" and "relative Basedow's disease." 

When the ovaries are removed at operation, the vasomotor and 
other disturbances which come on resemble more the symptoms 
of hyperthyroidism than any other condition of which we have 
any knowledge. In women who have not been operated on, in 
women at menopause or climacterium, and often in women who are 
not near the menopause age, we frequently see annoyances of the 
same nature, often combined with scanty menstruation and with the 
other evidences of ovarian insufficiency. Are we not justified in 
considering the relative oversecretion of the thyroid in them, too, 
as the pathologic basis ? 

According to Welles, the close relation between the thyroid and 
the reproductive functions is beyond question. The points in favor 
of these are the following: (i) The greater size of the thyroid in 
females; (2) the enlargement of the thyroid in menstruation and 
pregnancy; (3) the tendency to develop goiter during pregnancy; 
(4) early atrophy of the thyroid after the menopause; (5) loss of 
sexual appetite in many of the thyroid diseases; (6) 80 per cent, of 
all goiters, 80 per cent, of myxedemas, and most cases of Graves' 
disease occur in the female; (7) Halsted observes that bitches 
that have lost part of their thyroids, when impregnated show 
evidences of athyreosis as the time of parturition approaches, which 
disappears soon after the litter is born; (8) all of the pups of these 
litters have thyroids many times the normal size; (9) "even in 
dogs, if they are old, thyroidectomy is neither fatal nor accompanied 
by the usual symptoms; Kocher points out that post-operative 
myxedema scarcely occurs at all in elderly people" (Thomson). 

Thomson explains the frequency of Graves' disease in women 
"by the proneness of women to gastro-intestinal derangement in 
connection with menstruation and pregnancy and menopause." 
In our opinion it is just at these three stages that ovarian inactivity 
or insufficiency and ovarian relation to the thyroid would produce 
the annoying combination of nervous symptoms easily mistaken 
for hysteria or neurasthenia and resembling or actually representing 
aberrant forms of Basedow's disease. Even if Thomson is correct 
in his statement, we must still reason out what makes women prone 



306 MEDICAL GYNECOLOGY 

to gastro-intestinal disturbances in connection with menstruation, 
pregnancy, and menopause. May not the proneness to gastro- 
intestinal disturbance be the result of the metabolic changes which 
occur at menstruation, pregnancy, and menopause? And if they 
are the result of the metabolic changes, then what more rational 
idea have we than that ovarian and thyroid interrelation, always of 
a fluctuating rather than of a stable character, produces through 
hyperthyroidism not alone annoying nervous symptoms, but in- 
numerable variations in the severity of the symptoms ? 

Perhaps in the climacterium the annoying nervous symptoms 
are less if the thyroid atrophies coincidentally with the ovaries, 
and perhaps the symptoms are more annoying if the thyroid atro- 
phies more slowly than the ovaries. 

Perhaps in the climacterium the excitable cases are those with 
too much thyroid, and the depressed ones with too little. 

Possibly after operations the thyroid atrophies on absence of the 
ovaries, quickly in some cases and slowly in others, as probably 
happens at the normal climacterium. The patients grow stout, 
probably because the ovarian, and later the thyroid secretion, no 
no longer stimulates tissue metabolism; in some cases possibly 
because, the thyroid secretion being diminished or non-function- 
ating, there is a " relative myxedema." 

The probabilities are that ovarian insufficiency in many cases 
means relative hyperthyroidism. The least we can say is that the 
symptoms resulting from diminution or absence of ovarian secre- 
tion, and the symptoms of hyperthyroidism, are sufficiently alike 
to express the opinion that they are one and the same. 

Administration of Thyroid Extract. — It is of interest to follow 
the action of thyroid extract, particularly in patients who have 
lost both ovaries at operation. Among such cases there are those 
who suffer absolutely nothing annoying after the castration. There 
are others who suffer in a mild degree and others in a very marked 
degree. In administering thyroid extract to some of these patients, 
I have observed that in the first class there are produced some 
flushes and some irritability, but no marked results. In the second 
and third class of cases, each and every one of the annoying symp- 
toms is markedly increased. So noticeable is the sensitiveness to 
thyroid, and so marked is the increased severity of the symptoms, 



ASSOCIATED NERVOUS CONDITIONS 307 

that one can scarcely doubt that hyperthyroidism is the cause of 
the symptoms in the first instance. 

On the other hand, the moment the thyroid extract is stopped 
and the patients are again put on ovarin, the annoying symptoms 
cease and almost entirely disappear. I have administered ovarin 
and followed its action in over forty cases of double oophorectomy, 
with or without loss of the uterus, and have in only two cases 
failed to observe an almost entire absence or disappearance of 
annoyances, especially if the ovarin was administered soon after 
the operation. On the other hand, I have not been able to secure 
the same brilliant results by the administration of ovarin in cases 
of natural menopause or climacterium, as have been published by 
other authorities. Yet I have seen enough of its beneficial, though 
slower, effects to feel satisfied of its specific action. 

After castration the reduction of oxygen exchange amounts to 
20 per cent., the general gas exchange being likewise diminished; 
the weight, as a rule, increasing. The effect of ovarin, if given 
within two or three months after castration, not only overcomes 
this change, but increases the gas exchange above the normal, 
this increase lasting a variable time and diminishing gradually. 
On normal animals no effect is observed. The use of preparations 
obtained from the male organs exerts no effect on the female 
deprived of ovaries. 

We must remember that ovarian extract has the effect of increas- 
ing oxidation, and perhaps of increasing the elimination of waste 
products, and the good results might be explained on this ground, 
were it not for the specific action of ovarin when administered 
after castration. Thyroid extract, as is known, increases oxida- 
tion, and especially aids elimination, and produces marked meta- 
bolic changes. This may account for the good effects obtained 
by the administration of thyroid, even in certain conditions in 
which one would naturally expect thyroid to act injuriously. 
Good results have been published very generally on the administra- 
tion of thyroid in simple struma. Many have published good 
results from the administration of thyroid in Basedow's disease, 
and, as is well known, numerous cases of obesity react beautifully 
to the careful administration of thyroid extract. On the other 
hand, several exact observers, while acknowledging the value of 



308 MEDICAL GYNECOLOGY 

thyroid extract in simple struma and obesity, have noted absolutely 
no beneficial influence in cases of Basedow's disease. Most of us 
know that thyroid extract almost always increases the annoyances 
associated with exophthalmic goiter. The beneficial effect of 
thyroid extract in certain mental diseases is explained on the 
theory that the metabolic and other changes which it produces in 
the brain cause a reaction, which in some instances is beneficial. 
On the other hand, as might be expected, numerous cases are 
uninfluenced or harmed thereby, especially if in them the element 
of hyperthyroidism is present. 

States Allied to the Climacterium. — We observe in women 
who are not near the climacteric age, in women who have local 
disturbances of various natures, and in women who have none of 
these local disturbances, symptoms of very much the same character 
as are typical of the climacterium, either natural or artificial. 
While the flushes are not marked or are absent, yet these women 
have palpitation, irritability of temper, mental depression, psychic 
unrest, dizziness, sleeplessness, and intestinal disturbances. It is 
these points which have given rise to the diagnosis of reflex neurosis, 
neurasthenia, hysteria, etc. It is fair to suppose that in many of 
these cases we are dealing with aberrant forms of Basedow's 
disease, or with ovaries which are either not producing a positive 
secretion that is needed, or which are not producing a proper secre- 
tion to nullify such other substances as are able to produce the 
symptoms that occur in the climacterium, natural or artificial. 
In many cases a comparison of the symptoms with those of the 
climacterium, and with the symptoms of aberrant forms of Base- 
dow's disease, had led me to believe that they, as well as the typical 
annoyances of the climacterium, are due to hyperthyroidism. It 
is very often hard to distinguish between many forms of "ner- 
vousness," on the one hand, and slight or aberrant forms of 
Basedow's or Graves' disease, on the other. 

In only a few of these cases is there persistent tachycardia, but in 
all, at various times, one or other of the cardinal symptoms have be- 
come markedly noticeable. In all of them the mental irritability, 
the tendency to magnify slight details, the mental unrest, the sleep- 
lessness, palpitation, attacks of weakness, etc., are like the symp- 
toms of the climacterium. From our knowledge of this condi- 



ASSOCIATED NERVOUS CONDITIONS 309 

tion we must consider the etiology to be a relative degree of hyper- 
thyroidism. 

That the condition of hyperthyroidism may occur in patients 
without marked pelvic involvement is self-evident. If it may occur 
in such cases, there is more warrant for accepting a like condition 
when ovarian function is disturbed by pelvic disease of a circula- 
tory or inflammatory or atrophic nature, such as cases of Freund's 
disease. 

It would be strange if gynecologists had attributed, entirely with- 
out reason, to pelvic disturbances so many constitutional and nerv- 
ous symptoms in women. They have attributed them perhaps too 
much to these pelvic disturbances acting through reflex channels. 
There is certainly a large proportion of women suffering from 
so-called reflex symptoms who cannot be classed under hysteria or 
under neurasthenia, but in whom ovarian insufficiency or relative 
hyperthyroidism is probably present. It is often a difficult question 
from the standpoint of diagnosis, but the predisposition of the 
female to various combinations of nervous symptoms certainly 
points to a general state as the causative factor. 

The relation of the ovaries to normal functions of a special char- 
acter in women is decidedly clear; their relation to pathologic ner- 
vous states is highly probable. The weaker sex, with its tendency 
to these affections and to hysteria, will probably in the future be 
less frequently treated as possessors of nerves alone. It is not 
probable that ovarin replaces all that the ovaries should furnish, 
nor can ovarin in a short time overcome injuries long existing. 
That its action in the above-mentioned affections, supporting the 
theory of ovarian and thyroid interrelation, may lead to a more 
rational treatment of certain nervous conditions in the female, 
both medically and surgically, is not to be doubted. 

Realizing the relation of the ovaries to many of these nervous 
conditions, we may say, in the words of Virchow, "All peculiarities 
of the female body and mind, or nutrition and nerve function, are 
only a dependent of the ovary." 

THE HYGIENE OF PUBERTY 
The time when menstruation begins and stops, whether early or 
late, is often an inherited quality in many cases. It is wise to 



3IO MEDICAL GYNECOLOGY 

develop the resistance of the body, which is diminished by the onset 
of menstruation, so that the girl may meet with greater ease the 
demands which this awakening sexual function makes. The girl 
should be nourished and hardened. 

Nourishment. — The food should contain albumen and should 
be easy of digestion. There should be four to five meals each day. 
The food should consist of much meat, fresh vegetables, vegetables 
containing iron, such as spinach, beans, and peas. There must 
be freshly cooked fruit in large amounts. The evening meal 
should not be too rich or too succulent, and had best consist of 
eggs, omelet, milk, stewed fruits, etc. 

Exercise. — There should be plenty of exercise in the open air; 
not much if the girl is chlorotic. Simple gymnastics develop the 
muscles, aid in erect carriage, and develop respiration, circulation, 
and digestion. Room gymnastics are of very great value, and 
such work may be done in the gymnasium, or the use of medico- 
mechanics may be advised. 

Clothing. — Clothing ought to be of a kind which does not 
obstruct the circulation. Corsets for the young are injurious. 
Clothing must give freedom to breathing, to the thorax and ab- 
domen. There should be no tight bands about the neck or tight 
garters, and underwear should not irritate the genitalia. 

Sleep. — Eight to nine hours of sleep are sufficient and the rule 
to be followed should be "early to bed and early to rise." 

Routine. — A regular routine of life and regulation of work and 
responsibility is advisable. There should be active walking in the 
open air. Not too much time is to be spent indoors or at the 
piano or sewing-machine. The use of the bicycle is not advisable, 
but lawn tennis, skating, swimming, etc., are permitted. Litera- 
ture should be of a wholesome nature and the child must be 
watched to prevent the habit of masturbation. 

Hydrotherapy. — At morning and night we advise a two-minute 
cold sponge, 50 to 70 F., or a cold shower-bath lasting half a 
minute. If the girl is anemic or becomes chilled, administer a glass 
of hot milk or tea some time before the use of the water. Cold 
water ought not to be used for chlorotics. Scrofular or rachitic 
constitutions demand the use of salt baths. These girls are poorly 
developed and menstruate little or late. Sea baths are of value. 



ASSOCIATED NERVOUS CONDITIONS 311 

It is wise to begin at home with salt baths and to gradually lower 
the temperature so that the girl may become accustomed to sea- 
bathing in the open air. 

Climate. — The effect of climate in disturbances of menstruation 
and in nervous conditions, as well as in chlorosis, is very important. 
These states demand an elevation in the mountains of 3000 feet. 
This acts well on blood-formation and on menstruation, improves 
the appetite and digestion. If the pulse is irregular and frequent, 
if there is increased pressure in the arterial system, and if there is 
little resistance to fatigue, it is better to advise a medium elevation 
in a wooded country. In winter a mild climate is necessary for 
anemic and chlorotic girls. 

The skin demands special care, for girls at puberty are often 
liable to acne, comedones, seborrhea. 

In abnormal conditions of the pelvic organs a gynecologic 
examination should be made only when absolutely necessary, 
for it often has a bad effect on the psychic state. The girls imagine 
they are extremely sick. Gynecologic examination or treatment 
may cause erotic attacks and may end in a neurosis. 

Education. — The social relations of children at puberty should be 
closely watched ; girls are to be taught mild responsibility, and any 
tendency toward curiosity in the field of the sexual organs should be 
diminished. The literature, play, and amusements of growing 
girls should be observed, and social relations with the opposite sex 
ought to be controlled. They are not to be overburdened with 
mental work; there should be a careful combination of work and 
relaxation. They should be kept away from society, from the 
theater, from balls. Education is to be limited to the mental 
ability of each case. The mental qualities of associates should be 
noted. The girl at puberty must be kept from excessive religious 
enthusiasms. Literature of such a nature as does not spoil whole- 
some illusions is to be selected. Music, painting, etc., are to be 
considered simply as wholesome relaxations. Attention must 
be paid to the diet and physical exercise. The food should be 
of a mixed animal and vegetable nature, with little coffee or tea, 
with no alcohol. Attention paid to the proper daily evacuation of 
the bowels is essential. 

Corsets, if worn, should not constrict the body and should not 



312 MEDICAL GYNECOLOGY 

contain bones, and must act merely as a support for the skirt. It 
is easy to support the skirt from the shoulders by suspenders. 

In due time the young girl ought to be informed of her normal 
sexual processes and the meaning of this condition to health. She 
must be warned of its importance and its significance as a step 
in her normal life. 

Care During Menstruation. — During menstruation the ex- 
ternal genitalia should be washed twice daily with water at 85 F., 
and no full baths should be taken. Long walks, horseback-rides, 
dancing, etc., should not be indulged in. The menstrual period 
ought to be a period of rest and only simple easy work should be 
done. The bladder must be emptied regularly. Diet is to be 
wholesome and nutritious and free from watery foods, especially 
free of tea, coffee, wine, and beer. In chlorotics the diet must be 
extremely full for several days. 



TREATMENT OF CHLOROSIS 

In chlorosis feeding should be carried out every two or three 
hours. There should be plenty of albuminous food. Breakfast 
is to consist of meat, especially steak, zwieback, butter, tea, or 
coffee. Milk to the amount of one-fourth to one-half of a 
quart at each meal is to be given; more only if solid food is not 
well borne. There should be a rest of a half-hour before and after 
each meal. If girls are anemic and thin, there should be an in- 
crease of fats, such as milk, butter, and cream, and much carbo- 
hydrates, rice, potato puree, sago, tapioca, sweet fruits, dates, apples, 
chocolate, milk, and cocoa. Meals are to be given, say, at 7.30 
and 10 a. m., at 4, 7.30, and 9 p. m. If girls are anemic and fat, 
which condition is often due to lack of exercise and to free feeding, 
albuminous food should be given and only small amounts of 
carbohydrates and fat. The amount of fluids ought to be small 
in order to thicken the blood and increase the hemoglobin. 

During menstruation the diet should be actively pushed and 
should contain much albumen and fat and some carbohydrates. 
At 7.30 a. m. one-half quart of milk is to be taken slowly in bed. 
At 9 tea or coffee with milk, roast beef or steak, or chicken are 
given. At 11 one-fourth quart of milk, bread and butter, or 



ASSOCIATED NERVOUS CONDITIONS 313 

two eggs. Lunch consists of meat, vegetables, potatoes, plain 
dessert, fruit. At 4 p. m. coffee with milk, and bread and butter 
are taken. The feeding at 7 p. m. should be of the same amount 
as at lunch, or rather less in amount. Soups are to be avoided. 
If these patients do not care for meat, it may be substituted by 
milk, bouillon, fruit, cocoa, rice, etc. 

In chlorosis too much exercise ought not be advised. In fact, 
in severe chlorosis rest in bed of from four to seven weeks is advisa- 
ble. Tepid sponge-baths should be given morning and night. 
Sweat-baths are said to increase the number of red blood-cells, the 
hemoglobin, and the body- weight. Hot baths three times a week 
at a temperature of 105 F., and of a duration of fifteen minutes to a 
half hour, are of value, especially if followed by a cold douche 
lasting only a few seconds, or by a cold rub. This must be 
followed by a complete rest of one hour. These hot baths are to 
be continued for a period of from four to six weeks. They have a 
tendency to improve all the annoying symptoms. Nauheim 
baths are especially valuable for chlorosis or anemia. They are 
of importance because they can be given at a lower temperature 
than other baths. They act on the nervous centers and influence 
metabolic processes. They ought to be given at a temperature of 
from 90 to 95 F. and of a duration of ten to twenty minutes (Kisch). 

Of great importance is the care of the intestines, and their action 
must be regulated. It is advisable, once a week, to administer at 
night a blue-mass pill, 3 to 5 grains, to be followed the next morning 
by a saline cathartic. Iron is the specific in the treatment and 
is used in the form of Blaud's pills, ferratin, or any of the numerous 
iron preparations, such as ovoferrin. Ovarin is of value as an 
aid to iron and ought to be administered in all cases. A com- 
bination which I use consists of a capsule taken three times a day 
after meals containing ferri carbonas, 3 to 5 grains; arsen-hemol, 
ij grains; ovarin, 3 grains; extract of cascara, h to 1 grain. 
Arsenic in the form of Fowler's solution may be given with ferro- 
mannin. 

Iy. Massa Blaud's (Fischer's) gr. v 

Acid, arsenos gr. ^ 

Ext. nuc. vomic gr. \ 

Ext. case, sagrad gr. \ 

M. Ft. tal. caps. no. xxx. 
S. — One p. c. 



3 X 4 MEDICAL GYNECOLOGY 

I£. Liq. potassi arsenitis 5iss 

Ferro-mannin § vi 

S. — 3ij t. i. d. p. c. (Goodhart.) 

1$. Ovarin (Merck) gr. iij 

Arsen-hemol gr. iss 

Ferri carbonatis. gr. iij 

Ext. cascara gr. ss 

M. Ft. tal. caps. no. xxx. 

S. — One t. i. d. p. c. 

TREATMENT OF NERVOUS CONDITIONS 

Conditions associated with diminished excretion of urea demand 
care in the choice of diet. Red meats are to be excluded and only 
selected vegetables and fruits are to be permitted. I have obtained 
good results by following the practice of William H. Thomson, 
who administers blue mass, 5 grains, once a week at night, and 
who advises the administration of sodium phosphate every morning 
in hot water and 10 grains of sodium benzoate after each meal. 
In addition to that, he advises the administration of tincture of 
.aconite for a period of two weeks, followed by the use of nitro- 
glycerin. 

In the treatment of onanie the greatest difficulty is experienced. 
Not infrequently, when examination is possible, proof of the 
existence of this habit is given by observing hypertrophy or elonga- 
tion of one or both labia, a condition to which Dickinson has called 
attention. This alteration is produced by either manual touch 
of the parts or by rubbings in the seated position with the legs 
crossed. There is often seen a granular moist condition of the 
small labia and the vestibule is covered by a clear, moist, mucous 
secretion, and from the vagina comes a hypersecretion of cervical 
mucus. The condition is by no means infrequent in married 
women. There is great difficulty in questioning patients, and 
suggestions as to its avoidance are not calmly taken. However, 
patients should be made aware of this condition and its dangers 
should be pointed out. An active physical life should be advised, 
muscular exercise should be ordered, and outdoor sports, especially 
tennis and swimming, are to be recommended. Horseback- 
riding and the use of the bicycle should be avoided. 

In married women a condition allied to this is furnished by coitus 
interruptus, a procedure which produces pelvic congestion and 
nervous excitement, sometimes of marked nature. In addition, 



ASSOCIATED NERVOUS CONDITIONS 315 

this condition causes congestion and hyperemia which not infre- 
quently result in profuse menorrhagia or metrorrhagia. On the 
correction of this abnormal sexual practice and the regulation of 
the process the symptoms, not alone general but local, often 
improve. We cannot attribute, however, nervous states in women 
to this factor alone. We must take into consideration a neuras- 
thenic or hysterical basis, and the desires and repulsions in sexual 
relation. A nervous predisposition is aggravated by coitus inter- 
rupts and by onanie. 

Retroflexions and retroversions per se cause little annoyance save, 
perhaps, backache. When they are associated with other pain, 
some associated condition in the adnexa is the responsible factor. 
Acquired retroflexions are the result of labor, and when they "pro- 
duce" nervous or other symptoms, the retroflexion is usually found 
to be part of a general ptosis. With this splanchnoptosis there is 
associated a general asthenic physical and nerve state, and there 
is undue reaction to all stimuli, both subjective and objective. 
Patients with a psychopathic predisposition suffer most from this 
general asthenia of subinvolution. 

The treatment of general subinvolution is discussed under that 
special section. In some cases it demands an Alexander-Adams 
or other operation. In addition, it demands the use of general 
tonics, especially strychnin and the hypophosphites, attention to 
the bowels, the wearing of an abdominal belt, abdominal massage, 
the sinusoidal current, and a course of carbonated saline baths. 
The use of ovarin is always advisable. In some instances associ- 
ated with marked physical and mental asthenia a modified Weir- 
Mitchell cure is of value. 

Local treatment for tangible lesions should be practised unless 
contraindicated by excessive nervousness of the patient. 

Dysmenorrhea, fluor, pain, pruritus, onanie, deserve our most 
careful attention. The treatment of these conditions by no means 
always causes a disappearance of existing neuroses or of vasomotor 
or psychic disturbances. The correction of pathologic changes, 
especially such as have seemed to cause the general nervous state, 
are advisable and valuable procedures, but must be associated 
with general treatment of the nervous condition. 

Backache, pelvic pain, leukorrhea, etc., are troubles of which the 



316 MEDICAL GYNECOLOGY 

patient is conscious. In nervous women auto-suggestion may 
cause a marked reaction to such annoyances ; patients magnify the 
significance of the condition and many become so introspective in 
their study and thought of their pelvic state as to feel absolutely 
certain that only operative cure of the local annoyances will re- 
store their nervous systems to the normal. 

On the other hand, if patients of a nervous type are made aware 
of the existence of a movable kidney, of an enteroptosis, of a retro- 
flexion, of a lacerated cervix or erosion of the cervix, and if the 
physician attributes to these alterations the causation of the nervous 
symptoms, the physician by ectosuggestion often aggravates the 
patient's nervous state by fixing her attention on a local condition 
which has nothing to do with her nervous symptoms or which 
is often only part of a general state. 

Pain must be relieved, for nothing so depresses the tone of the 
nervous system, aside from its bad effect on appetite and sleep. 
Long-continued pain wears down the nerve resistance of the patient. 
Backache and headache may be due to constipation or to dimin- 
ished excretion of urea or to conditions which may be relieved by 
the administration of aspirin, vini colchici, iodid of strontium, 
ergot, or the glycerophosphates. For temporary relief or for the 
relief of hemicrania or pain in any part of the body increased 
during menstruation, the coal-tar products, as prescribed for dys- 
menorrhea (p. 165), are the best. Pelvic pain and backache often 
yield to local treatment for pelvic inflammations, congestions, and 
ptoses. If a cause cannot be felt bimanually, pain is often re- 
ferred to neurasthenia or hysteria. This is a great error and does 
innumerable patients injustice. It does take slighter alterations to 
produce annoyance in patients who have a predisposition to ner- 
vousness or to mental asthenia or whose life has been such as to 
produce a lack of nerve tone, but almost invariably there is a re- 
sponsible concrete factor which is productive of pelvic pain and 
backache. If pelvic pain fails to yield to treatment, operation is 
often necessary for the removal of the cause before the nervous con- 
dition can be relieved. This refers especially to ovarian pain, where 
removal of the ovary, tube and varicosities is often the only cure. 

Ovarian neuralgia is benefited by warm baths, warm applica- 
tions to the abdomen, blisters applied to Morris' points, and warm 



ASSOCIATED NERVOUS CONDITIONS 317 

vaginal douches. If the ovarian neuralgia is a symptom of neu- 
rasthenia or hysteria (?), the primary condition must be treated. 
If the pain is severe, hypodermic injections of antipyrin may be 
used if the internal administration of the coal-tar products brings 
no relief. The hypodermic use of morphin should be avoided if 
possible. Electricity is sometimes of value (p. 119). 

In nervous and neurasthenic conditions alcohol, tea, and coffee 
should be avoided. Much leisure should be spent in the open air 
and exercise should be advised and kept up as a habit. Weighty 
responsibility should be avoided. In severe cases absolute rest 
is an essential in treatment. Reading and mental exertion should 
be avoided. The diet is to be light and easy of digestion and 
the bowels should be carefully regulated. In acute cases a nurse 
should be in charge of the patient. Isolation, according to Clarke, 
is at first not necessary, but if the patient does not improve, iso- 
lation and treatment away from home should be advised. Gentle 
rubbing of the whole body or the sheet-bath once or twice a 
day is valuable. A small dose of alcohol may sometimes relieve 
nervousness and promote sleep. For insomnia a sheet-bath is 
given in the evening. Hot sponging to the spine or a wet pack 
is of value, to be reinforced, in case of failure, by drugs. For the 
sleeplessness and excitement baths of 8$° to 95 F. are restful. 
Care must be taken to avoid sleeplessness becoming a habitual 
complaint, and drugs such as bromids, chloral, trional, sulphonal, 
and veronal must be used, but not too long. In severe cases a Weir- 
Mitchell treatment is advisable. The diet should be full and 
nutritious and readily assimilated. Of the electric currents, the 
sinusoidal is excellent in many cases which are not severe enough 
to demand absolute isolation. If the condition of the patient is 
phlegmatic and psychic irritation is not marked, a course of Nau- 
heim baths is often of the greatest value in rousing and stimulating 
the patients, mentally and physically. Change of air and scene is of 
great benefit. Air at not too high an elevation is good. In indi- 
viduals of an irritable nature climate of even temperature is better, 
while in the phlegmatic type an elevation with stimulating air is 
good. Massage is excellent in many cases. Among drugs arsenic 
is of value, also valerianate of zinc in pill form, with a small dose 
of quinin and iron; compound syrup of hypophosphites ; the 



3l8 MEDICAL GYNECOLOGY 

glycerophosphates. Residence in the country, a quiet country life, 
exerts a soothing influence, and is one of the most useful means 
of treatment. 

The bromids are very essential in excitable states, for nervous 
and genital excitement, for nymphomania, onanie, etc. The 
addition of the glycerophosphates avoids a too depressing influence 
when long continued (p. 321). Bromids should not be given in 
exhaustion of a nervous or nutritive character. 

Strychnin is important in the treatment of functional atony and 
relaxation, in mental or physical exhaustion due to excitement and 
overwork. Dosage must be increased. 

1^. Zinci valerian. 
Quin. valerian. 

Ferri valerian aa gr. j 

Ext. cannab. indie gr. J 

Ft. tal. pil. no. xxx. 

S. — One p. c. 

The glycerophosphates of lime and soda may be given in capsules 
with or without the addition of other drugs, or they may be given 
in five-grain tablets. Each tablet contains — 



Calc. gly cerophosph gr. iiss \ 

Sodii glycerophosph gr. iiss / 



Known as duotonol 



Or— 

Calc. glycerophosph gr. iiss 

Sodii glycerophosph gr. iiss [■ Known as triotonol 

Strychn. glycerophosph gr. g T 



Or— 

Calc. glycerophosph gr. iiss 

Sodii glycerophosph gr. iiss 

Quinin. glycerophosph gr. \ 

Strychn. glycerophosph gr. -^ho 

Or— 

Calc. glycerophosph gr. i j 

Sodii glycerophosph gr. i j 

Ferri glycerophosph gr. \ 

Mang. glycerophosph gr. \ 

Quinin. glycerophosph gr. \ 

Strychn. glycerophosph gr. 2170" 



Known as quartonol 



Known as sextonol 



Overfeeding is often an essential procedure in many of these 
cases, especially in those who have lost in weight or who have limited 
themselves to a restricted diet because of real or imaginary inabil- 
ity to digest certain foods. The very best method of overfeeding 



ASSOCIATED NERVOUS CONDITIONS 319 

these cases is to give them a diet which at the same time overcomes 
the constipation which is very often an associated annoyance and 
to which many patients attribute all their ills. (See section on 
Constipation.) Overfeeding is of value for the treatment of 
splanchnoptosis and the nervous, asthenic, and excitable con- 
ditions comprised under the terms nervousness, neurasthenia, and 
hysteria. Food can be taken in large amounts if given every 
hour or two in small portions. Absolute rest in bed is not always 
necessary; a certain amount of exercise is beneficial and promotes 
appetite. Milk, cream, cocoa, and chocolate should be given. 
Butter, eggs, and nutritious preparations in the form of thick cereal 
or cream soups are of value. Butter, the yolk of eggs, plasmon, 
somatose, sanatogen may be added to the soups. Puddings, toast, 
zwieback, omelets, cereals with butter and cream, are well 
digested. Peas, beans, and lentils permit of the addition of butter. 
Fruit jellies, honey, compots, and fruits have a good effect on con- 
stipation. In obstinate constipation the grosser forms of vege- 
tables may be given. Of meats, the best are filet, veal, and fowl, 
which are to be prepared in pure butter. Fish may be added. 
Milk, however, forms an important part of the diet, but should 
not exceed two quarts a day. 

In the severe forms of neurasthenia a rest cure is all-important. 
This method is of great aid in the after-treatment of operated pa- 
tients, especially such as have been reduced to a very nervous 
condition by long-continued pain. The method followed by 
Dubois with slight modifications is excellent. He demands: (i) 
Several weeks (ten to twelve) spent in bed in quiet, away from 
home in a sanitorium. (2) Isolation, generally without visits or 
letters. Occasional visits, occasional epistolary relations, may be 
allowed if the patient is not too emotional, if trifles are not too 
annoying, if family affairs are pleasant. (3) Overfeeding. For 
the first six days only milk is given, every two hours from 7 a. m. 
to 9 p. m. in divided amounts. Twenty-four ounces are given the 
first day, thirty-six the second, forty-eight the next day, fifty-seven 
the fourth day, sixty ounces the fifth day. On the sixth day sixty 
ounces are given and at breakfast time, i. e., with the first dose of 
milk, bread, butter, sweets or honey are added. On the seventh 
day the diet changes to the following : 



320 MEDICAL GYNECOLOGY 

Breakfast. — Milk, 12 ounces, bread, butter, honey or preserves. 

10 a. m. — Milk, 8 ounces (or matzoon). 
Lunch. — Full meal, varied and copious (especially as to butter and 
vegetables). 
4 p. M. — Milk, 8 ounces (or matzoon or buttermilk). 
Supper. — Full meal, varied and copious, especially as to vegetables 
and stewed fruits. 
9 p. m. — Milk, 8 ounces. 

The dislike for milk usually disappears. By the addition of 
lime-water, sugar of milk, pepsin, etc., its digestibility and action on 
the bowels can be regulated. Constipation lasting three days is 
overcome by a high enema. Later on the amount of food taken 
overcomes this tendency. If it persists, a suppository of glycerin 
may be given at the same hour each morning after breakfast to ac- 
custom the patient to regular evacuations. 

The patient should have the time and interest of the physician, 
for the influence of the physician is an important factor; to Dubois, 
almost the all-important factor. To him psychotherapy, the 
therapy of suggestion, plays an essential role. I heartily recom- 
mend the reading of his work on "The Psychic Treatment of 
Nervous Disorders," translated by Jellifle. While perhaps ex- 
treme in the scope claimed for it, except in the hands of the ex- 
perienced and gifted, it shows the marked value of psychotherapy, 
a therapy which many practice unconsciously or consciously, but 
a therapy of the very greatest value in the treatment of many of the 
associated nervous conditions in gynecology. 

Climacterium. — A symptom of climacterium is the disturbance 
of vasomotor function characterized by flashes, dizziness, restless- 
ness, etc. These may be treated by baths of 90 to ioo° lasting 
fifteen minutes, which diminish the blood-pressure and are recom- 
mended by Gottschalk. For abdominal plethora and obesity, 
the use of Glauber's salts, general massage, and exercise are im- 
portant. If the nervous symptoms are most prominent and are of 
a sexual character, cool body douches are advisable. For sexual 
excitement the bromids, heroin, and hyoscin are helpful. Ovarin 
(gr. v, t. i. d.) combined with sextonol (gr. v, t. i. d.) should be 
given in all cases. Strychnin, glonoin, and digalen may be necessary. 

In the treatment of those conditions of a nervous nature com- 



ASSOCIATED NERVOUS CONDITIONS 32 1 

plicated by profuse bleedings, the use of ergotin, stypticin, and 
hydrastinin is essential. The carbonated saline baths are more or 
less contraindicated when profuse bleedings are a symptom, and 
under like circumstances the administration of ovarin should not 
be practised too regularly. When the nervous conditions of the 
climacteric age are accompanied by a gradual diminution of 
menstruation, many of the patients are benefited by ovarin (gr. 
v, t. i. d.) and carbonated saline baths. 

It is in many of these excitable nervous cases that the use of 
bromid and glycerophosphates gives us very good results. I am 
in the habit of administering 5 grains of sodium glycerophosphate 
and 10 grains of strontium bromid in one dram of water, or elixir of 
pepsin, three to four or more times a day. This combination is of 
the greatest value in the excitable forms of nervousness discussed in 
this section. 

1^. Strontii bromidi oiv 

Aq. menth. pip 5 ii j 

S. — j every four hours in water. 

1$. Strontii bromidi oiv 

Sodii glycerophosph 5ij 

Elixir pepsini 5iij 

M. S. — 5 j t. i. d. p. c. and at night in water. 

In the treatment of cases of hyperthyroidism, or of aberrant 
Basedow's disease associated with tachycardia, ovarin, 5 grains, 
should be administered with whatever form of treatment is used. 
Local treatment, ovarin, and the use of mild carbonated baths 
often aid in putting cases of hyperthyroidism in good condition. 
Rest should be advised. Meat and sea-food should be forbidden. 
A vegetarian diet is advisable. Sodium phosphate, o j in hot water 
a half hour before breakfast, should be ordered. Intestinal fermen- 
tation is to be prevented by a pill of blue mass (gr. v) once a week 
and by sodium benzoate (gr. x) in capsules one hour after each 
meal, this being the method W. H. Thomson follows in the treat- 
ment of Basedow's disease. In all cases in which both ovaries 
have been removed the routine administration of ovarin, 5 grains 
three times a day, should be practised shortly after the operation. 

Owing to the value of the carbonated saline baths, especially 
in depressed nervous conditions as well as in local states, the sec- 
tion on Nauheim Baths deals with the indications for their use and 
with the mode of application. 
21 



CONSTIPATION* 

During digestion peristaltic contractions of the smooth muscula- 
ture of the intestinal wall take place which propel the contents 
from the pylorus toward the anus and mix them with the digestive 
juices. The nerves of the intestinal mucosa are excited by the 
normal chyme. This excitation is transmitted to the muscularis 
through the plexuses of Meissner and Auerbach, automatic nerve- 
centers situated in the submucous and muscular coats respectively. 
But peristalsis, normal as well as pathologic, is also under the 
influence of the cerebrospinal system; irritation of the vagi stimu- 
lates, irritation of the splanchnics inhibits it. The anal orifice is 
closed through the tonus of the sphincter muscles, aided by the 
levator ani. The fecal column in its descent through the rectum 
produces a reflex contraction of the sphincters or a short augmen- 
tation of their tonus which we interpret as the desire to go to stool 
(nervi hypogastrici and erigentes; lumbar enlargement of the 
cord). Then a relaxation of the external sphincter takes place 
through voluntary cerebral inhibition, rectal peristalsis continues, 
the abdominal press is set in motion, the levator ani contracts 
and lifts the anus over the advancing column. 

The chyme passes through the small intestine (20 feet) in two 
to six hours, through the colon (5 feet) in twenty to twenty-four 
hours. The remains are stored in the sigmoid and upper rectum. 

The feces are derived from three sources: (a) Food residue; 
(b) intestinal contributions; (c) bacteria. The food residue con- 
sists of the indigestible parts of the ingesta and of the digestible 
portions which for some reason have escaped digestion and as- 
similation. The intestinal contributions are the digestive juices 

* This section has been written by Dr. George B. Mannheimer. His methods 
of treating constipation have been long adopted by me. The hygienic, dietetic, 
and mechanical procedures used in the treatment of constipation are of very great 
value in improving the general physical tone, and include many of the methods 
which I have found of greatest aid in the treatment of asthenia and many nervous 
conditions in women. 

322 



CONSTIPATION 323 

which have not been reabsorbed, intestinal mucus, and desqua- 
mated epithelia. The amount of bacteria varies considerably. 

Starvation-feces are made up largely of bacteria, intestinal 
mucus, and desquamated epithelia. 

The normal quantity of feces passed by a healthy adult living 
on a mixed diet ranges from 130 to 250 gm. (4 to 8 ounces approx- 
imately), of which 35 to 70 gm. are dry residue and 75 per cent, 
water. It is much larger on a vegetable than on an animal diet. 

The term constipation cannot be accurately defined. Generally 
speaking, it means an infrequent or insufficient evacuation of the 
bowels. 

Most healthy adults have one movement a day, some have two 
or three, and others one in two or three days. These variations in 
frequency and quantity become pathologic when they produce sub- 
jective or objective disturbances, be they ever so slight, in the in- 
testinal tract, in remote organs, or in the general condition. 

In this chapter we wish to discuss only the so-called habitual 
constipation of adults. We are not concerned with constipation in 
infants and children, with acute constipation in febrile diseases or 
after operations and injuries necessitating rest in bed, with those 
forms of symptomatic constipation which are due to organic dis- 
eases of the digestive tract, to pelvic diseases, to cardiac, pulmo- 
nary, or renal trouble, to mental or other disturbances of the 
central nervous system, to systemic diseases, such as anemia, 
diabetes, etc., or to intoxications, such as lead poisoning. 

By habitual constipation we understand a condition which is 
based on the habits of the individual, a condition for which we 
find no tangible anatomic cause, and which therefore forms an 
apparently primary and independent trouble. We ascribe it to 
atony , i. e., lack of tone, of the intestinal musculature, a junctional 
weakness which renders the expelling forces unable to accomplish 
the work which they are expected to perform. Or we explain it 
by an abnormal innervation of the intestinal peristalsis, especially 
of the colon and rectum. Though we do not know the actual 
mechanism of this disturbance of nerve function, we must assume 
that muscular and neural disturbances are commonly associated, 
the former being the natural effect of the latter. 

Habitual constipation is much more common in women. Their 



324 MEDICAL GYNECOLOGY 

more sedentary life, their liability to pregnancy and the puerperal 
state with its atonic, asthenic sequelae, their tendency to peculiar 
local pelvic troubles which may interfere with or inhibit intestinal 
peristalsis, all lead to a constipation which is merely symptomatic 
in the beginning, but which is readily perpetuated into a habit, 
even after the original pelvic troubles are corrected. 



ETIOLOGY 

There may be a congenital weakness of intestinal peristalsis 
which manifests itself from birth and persists throughout life. It 
may run in families. But the commonest causes are acquired: 

i . Bad habits and unhygienic living, (a) Neglect to attend to 
the calls of nature. The normal desire for defecation is suppressed 
through laziness, mental preoccupation, ignorance, prudishness, or 
lack of time and proper facilities. With the poor, lack of decent 
and comfortable accommodations is a factor of no small importance. 
(b) Reading while at stool, thus diverting the attention from an 
act which requires full concentration, (c) All irregular habits of 
life, as irregular meals, sleeping hours, frequent trips, (d) Seden- 
tary occupations and lack of exercise ; factors, however, which are 
somewhat overestimated. 

2. Improper food. This usually refers to food which leaves too 
little residue and consequently produces in the colon a too slight 
peristaltic and secretory stimulus. Such is the food of many persons 
of the wealthy class, who consume highly nutritious and easily 
assimilated food-stuffs, principally nitrogenous. Others, especially 
dyspeptics, restrict their diet to what they consider easily digestible. 
The physician may be responsible for the evolution of constipation 
by prescribing a too one-sided diet. This cannot be avoided with 
diabetics, where we have to choose the lesser evil. Generally 
speaking, all exclusive dietary schemes, such as a milk diet, etc., 
act in the manner mentioned above. Even a strictly vegetable 
diet, which in the beginning powerfully excites peristalsis and 
secretion, producing copious passages, may also in the course of 
time overtax those functions and finally lead to atony. Some 
women exclude from their diet all fats and oils either because of 
dislike or because of the fear of obesity or of an injurious effect on 



CONSTIPATION 325 

the complexion. Poor teeth may prevent people eating what they 
ought, or produce dyspepsia and constipation through improper 
mastication. Many individuals abstain from water because they 
do not care for it or because they prefer to take it in the form of 
stimulating drinks, or because they fear that it conduces to obesity. 
This latter belief is absolutely unfounded. No amount of water 
taken during or between meals in itself will lead to obesity, unless 
the person develops a better appetite on drinking at meals. On the 
contrary, it is one of the tricks of some obesity cures to let patients 
drink as much water as possible before meals to fill the stomach 
and so reduce its capacity for solid food. Too little water is 
deleterious to normal intestinal peristalsis and secretion, as is 
shown by the fact that patients with pyloric stenosis are almost 
always constipated, because water is not absorbed from the 
stomach but only from the intestines. Diabetics are often con- 
stipated because they excrete so much water through the kid- 
neys. People who undertake severe physical or prolonged work 
which provokes profuse perspiration are apt to become constipated. 
It is not to be assumed that the water ingested simply dilutes the 
feces. We all know from experience that it may excite peristalsis 
when taken very cold (cramps), but its main action after its ab- 
sorption into the blood, the plasma of which contains 90 per cent. 
of water, consists in furnishing the principal material for most 
secretions, including the digestive juices. It must be mentioned 
that constipating substances are often ingested with food and drink, 
wittingly or unwittingly; for instance, large quantities of lime in 
some drinking-waters, alum in adulterated flours and baking- 
powders, salts of lead in cheap candies, salts of copper in pickles 
and condiments, and, last but not least, iron given or taken for 
medicinal purposes during a too prolonged period. 

3. An abnormally vigorous digestion (Schmidt and Strasburger). 
Some persons digest substances which are usually not attacked by 
the digestive juices and they assimilate more of their food than is 
done by the average channels of assimilation. They, too, have too 
little residue left in their bowels; they have fewer intestinal bac- 
teria, less fermentation and putrefaction, and as an ultimate result 
too scanty and too infrequent movements. 

4. The abuse of aperients, a wide-spread evil. Physicians, 



326 MEDICAL GYNECOLOGY 

druggists, and laymen are responsible for it, and women especially 
have acquired the habit of self-dosing. In general, purgatives and 
laxatives are used too readily and indiscriminately for all sorts of 
conditions and complaints. Their use is persevered in too long or 
repeated too often in spite of the obvious fact that after a thorough 
cleansing there is nothing left for the bowels to work upon, and 
that a period of apparent constipation is necessary for the re- 
establishment of natural action. 

Hospital and dispensary physicians are great offenders in this 
respect. In many hospitals it is the routine to administer a purge 
to almost all patients on admission and to continue some form 
of laxative or enema throughout the whole stay, even with patients 
who had no intestinal difficulty before. This entire matter is 
left to the discretion of the house-staff, men fresh from college, 
who are not familiar with the strict indications for the administra- 
tion of aperients (although they know the difference between 
castor oil and croton oil, between a hydragog and a cholagog), 
and who do not realize that the patient's intestinal functions may 
be permanently damaged thereby. 

In dispensaries this practice is as bad or worse, not only in the 
medical divisions, where most cases of symptomatic and idiopathic 
constipation are treated, but also in the neurologic, gynecologic, 
and dermatologic departments. So many nerve and skin affec- 
tions are ascribed to autointoxication resulting from constipation, 
so many pelvic affections in women are ascribed to or supposed 
to be aggravated by constipation, that it is small wonder that 
physicians prescribe aperients galore. We believe that the auto- 
intoxication theory is carried entirely too far. In the medical 
division constipation cases excite no particular interest. They are 
usually dismissed with a prescription calling for salts or cascara, 
etc., and perhaps with offhand dietetic directions. Rarely does 
the physician go into the etiology. Rarely are full and proper 
dietetic directions given. Seldom are physico-therapeutic measures 
prescribed or administered. The physician excuses himself on the 
ground that he has nothing else at his command, and that dis- 
pensary patients are not satisfied unless they get a prescription. 

While speaking of drug-abuse, I wish to mention that the use 
of narcotics is often a self-evident cause of constipation. 



CONSTIPATION 327 

5. Weakness of the abdominal and perineal muscles, for which 
pregnancy and parturition are common causes. I wish to em- 
phasize the fact that the so-called abdominal press (abdominal 
muscles and diaphragm) has nothing to do with peristalsis proper, 
and that this aid comes into play only with the act of expulsion of 
the feces from the lower rectum, as is likewise the case with the 
levator ani. 

6. Mental and nervous influences. Just as a sudden fright is 
known to produce diarrhea, so worry, grief, and other depressing 
emotions may inhibit peristalsis. Prolonged mental effort acts 
similarly. Hysteria and neurasthenia, so called, are frequently ac- 
companied by constipation. The disturbed nervous equilibrium 
which affects almost all the body functions also upsets normal 
peristalsis and secretion. 

7. All factors which debilitate the entire system. In chronic 
diseases with progressive emaciation and debility the intestinal 
functions may naturally become weakened. 

Frequently several of the aforementioned causes are at work 
simultaneously. 

Habitual constipation is common in old and in obese people. 
With advancing years the muscular and glandular structures and 
functions deteriorate; food is selected more carefully and active 
exercise is not indulged in. 

In obesity great masses of fat in the parietes, in the omentum 
and mesentery may act as a mechanical impediment to peristalsis 
and the intra-abdominal circulation. To these is added the well- 
known repugnance of stout people to active exercise. 



PATHOLOGY AND PATHOGENESIS 

Adhering strictly to our original definition, there can be no 
pathology of habitual constipation. No one succumbs to this 
malady except those rare cases of idiopathic dilatation of the colon 
where obstinate constipation begins at birth, persists into adult 
life, with ballooning of the abdomen, and where enormous dilata- 
tion of the colon and sigmoid is found to be associated with hyper- 
trophy of the muscularis and secondary ulceration of the mucosa 
(Hirschsprung's disease). There have been many autopsies on 



328 MEDICAL GYNECOLOGY 

cases with antecedent history of habitual constipation, but who have 
died from other diseases or from injuries. In a very few of them 
degenerative changes were discovered in the splanchnics, the motor 
nerves of the longitudinal fibers. In a few others the only anomaly 
found was a muscularis of the colon below the average thickness 
(0.12 to 0.25 mm. as against 0.5 to 1 mm.). This condition, which 
is doubtless responsible for defective peristalsis, is probably a 
congenital hypoplasia and cannot be recognized during life. It 
must be emphasized that these are not cases of general emaciation 
or cachexia where a priori muscular defects might be expected. 

However, three anatomic lesions have often been and are still 
mentioned as the underlying causes of habitual constipation: 
(1) Atrophy of the muscularis ; (2) peritoneal adhesions; (3) dis- 
placements of the colon. 

Atrophy of the muscularis occurs with or without atrophy of the 
mucosa, and is the outcome of intestinal catarrh, but not the in- 
variable result. Hence it plays no role as a causative factor of 
primary habitual constipation. It can rarely be recognized during 
life. 

Peritoneal adhesions are found generally in -the ileocecal region 
and at the hepatic, splenic, and sigmoid flexures. These are not 
the cause but the effect of chronic coprostasis, through the medium 
of stercoral ulcers or of diverticula. Adhesions remaining after 
attacks of appendicitis, after gastric or duodenal ulcers, after lapa- 
rotomies, may, but rarely do, cause constipation. 

Displacement of the colon, especially of the transverse part, is 
often a sequence of its habitual overloading with stagnant fecal 
masses. The colon is simply dragged down by mechanical weight. 

Congenitally abnormal length of the sigmoid is a common cause 
of constipation, when this condition is not outgrown. Congenitally 
abnormal length or shortness of the mesentery may be responsible 
for displacement of the intestines, but usually these displacements 
are a part of a general splanchnoptosis. 

The habitus enteroptoticus which is congenital differs from the 
normal state in the following characteristics: Long, narrow, flat 
thorax; acute costal angle; floating tenth ribs; the epigastric and 
both hypochondriac regions are longer than wide; the viscera find 
better accommodation in the vertical than in the horizontal direction. 



CONSTIPATION 329 

If such persons lose flesh, especially parietal and omental fat, or if 
their abdominal walls become flabby and the recti gape, as after 
confinement, or if they lace tightly, the stomach, colon, and kidneys 
sink down and constipation often follows. Indiyiduals endowed 
with the enteroptotic habitus are specially prone to functional 
gastro-intestinal disturbances; or, in other words, their digestiye 
functions are upset by influences which do not affect a normal 
constitution. This habitus has therefore also been called as- 
thenia uniyersalis congenita (Stiller). This asthenia concerns pre- 
eminently the gastro-intestinal musculature (atony), but also the 
neryous system, and manifests itself in a yariety of neurasthenic or 
hysterical symptoms. Thus the common combination of enterop- 
tosis, atony (dyspepsia and constipation), and neryousness will be 
understood. 

SYMPTOMATOLOGY 

Habitual constipation is compatible with the enjoyment of full 
health. How long this can continue is difficult to determine. 
Such indiyiduals either haye a yery good neryous system or they 
disregard slight symptoms or become habituated to them, or else 
they belong to that class endowed with an abnormally vigorous 
digestion mentioned in the section on Etiology. 

Usually there are symptoms, either local or remote or general. 
The first are abdominal discomfort, fullness, tension, bloating, 
borborygmi, flatulence, bad taste, fetor; smooth, round or cylin- 
drical masses palpable in the sigmoid; dry, dark, hard scybala. 
Slight pain is not unusual. Attacks of colic deserve special con- 
sideration. They sometimes dominate the clinical picture to such 
a degree that these cases have been specially designated spastic 
constipation. Here the retention of the intestinal contents is not 
due to atony, but to spasm of the musculature. The stools are of 
small caliber, of pencil or small finger shape, or small round balls 
like sheep-dung. These individuals are markedly neuropathic, 
and are usually women suffering also from pelvic troubles. Dur- 
ing a large part ! of their lives they have accustomed their bowels 
to cathartics. They may have acquired a simple or membranous 
enteritis. 

Boas mentions a third variety of habitual constipation which we 



330 MEDICAL GYNECOLOGY 

have also observed a number of times. The evacuations are frag- 
mentary, i. e.j insufficient, leaving behind a sensation of ab- 
dominal and rectal discomfort which compels the patient to go to 
stool repeatedly and pass small quantities of cylindric or spherical 
hard or pulpy masses. This variety occurs more frequently in 
men and seems to depend on a sluggishness of the sigmoid and 
rectum. 

With considerable coprostasis there may be very severe attacks 
of colicky pain with tympanites, fainting, even collapse and vomit- 
ing, reminding one of ileus. Backache is common. 

Of the remote organs the stomach is first affected by habitual 
constipation. There may be eructations, bloating, fullness, nausea, 
anorexia, pain up to severe gastralgia. Gastric ulcer may be simu- 
lated. 

The heart may also show symptoms, such as palpitation, dis- 
turbed rhythm, precordial oppression, up to pseudo-anginal attacks. 

The upward pressure of the diaphragm by accumulation of 
gases and feces may cause shortness of breath. 

Nervous symptoms are common, viz., pressure, heaviness or a 
feeling of heat in the head, lassitude, and dizziness; often head- 
ache, inability to do mental work, depression of spirits up to a 
well- developed picture of hypochondriasis. Insomnia is frequent. 
Facial neuralgia and hemicrania may also occur. 

Rectal accumulations may alter the position of the uterus and by 
direct pressure may give rise to sciatic, lumbo-abdominal, or pseudo- 
ovarian neuralgia. They may likewise produce dysuria. 

Albuminuria and cylindruria are by no means rare in chronic 
constipation. 

Anemia and chlorosis are by some supposed to be the conse- 
quence of chronic constipation (copremia — Andrew Clark). The 
strict proof of this causal connection is lacking. 

Stercoral fever is more often seen in infants and children than in 
adults. If women in the puerperal state or after gynecologic 
operations develop fever which is relieved by purgation, coprostasis 
per se is not the responsible factor. Pressure is possibly exerted 
on small pelvic inflammatory foci, which are thus more readily ab- 
sorbed, with the consequent production of temperature (Kustner). 

The pathogenesis of these various symptoms is to be explained 



CONSTIPATION 33 1 

in different ways, (a) Reflexes mechanically produced ; (b) symp- 
toms of a neuropathic disposition provoked by the intestinal trouble ; 
(c) intestinal auto-intoxication. 

These three hypotheses do not exclude each other. The first 
two are easily understood. A few words as to the last. From an 
extensive study of the literature the following conclusions can be 
derived. It cannot be proved by our present methods that simple 
constipation increases decomposition in the intestines. There is 
much less absorption from inspissated stagnating masses, such as 
form the contents of the colon in ordinary atonic constipation, than 
from stagnating fluid masses such as we find in defective peristalsis 
of the ileum and jejunum. 

Increase or decrease of intestinal decomposition need not be the 
consequence of motor disturbances, but may be the cause thereof. 
The normal products of fermentation and putrefaction, especially 
gases and volatile fatty acids, stimulate peristalsis of the large 
bowel. If because of improper food or of an uncommonly good 
digestion the food residue be small, the number of intestinal bac- 
teria is apt to decrease as well as the amount of decomposition 
products. Lastly, the quantity of aromatic bodies in the urine 
(indicanuria) is no accurate indicator of the amount of bacterial 
activity in the intestine, nor of decomposition and absorption of 
bacterial products. 

Habitual constipation rarely exists for any length of time without 
the development of one or more of the following sequelae : Hem- 
orrhoids, anal fissure, catarrhal inflammation of the whole or part 
of the colon or rectum, ulceration (stercoral ulcers), dilatation, 
coproliths, displacements, diverticula, and hernia (from habitual 
straining). The more serious sequelae are appendicitis (from fecal 
concretions), peritonitis (from ulcers or diverticula), and intestinal 
obstruction. 

DIAGNOSIS 

A diagnosis of constipation is generally easy. Patients usually 
tell us they are constipated and have to use artificial help to pro- 
cure passages either regularly or frequently (complete constipation), 
or only at intervals (incomplete constipation). But then it is 
incumbent on us to determine whether we are dealing with a pri- 



33 2 MEDICAL GYNECOLOGY 

mary idiopathic habitual constipation or with a symptomatic one; 
i. e., we must exclude all conditions, local, remote, or general, 
which may give rise to constipation. This requires a thorough ex- 
amination of the entire body. We should never omit to make a 
rectal and vaginal examination. How else can we recognize rectal 
cancer, so commonly accompanied by coprostasis; or those much 
disputed rectal folds (Houston's valves) which when hypertrophied 
offer a mechanical impediment to the descent of the feces ; or fecal 
accumulations in a wide ampulla which are, for instance, always 
found in fragmentary constipation even immediately after an 
evacuation; or the empty contracted rectum in spastic constipa- 
tion; or uterine displacements and pelvic exudates? A careful 
palpation of the abdomen will give the most valuable information. 
Aside from neoplasms, and other structural lesions which may 
have to be excluded, it will reveal that most characteristic ob- 
jective sign of chronic constipation, fecal tumors. They are of 
doughy consistence, of bead-like arrangement, moldable by press- 
ure, movable, and affected by purgatives or enemata. But some- 
times these characteristic symptoms are absent, and then the 
differential diagnosis between fecal and other abdominal tumors 
becomes extremely difficult. We cannot enter into differential 
diagnostic details. We only wish to mention here one diagnostic 
method which is neglected too much — probatory lavage of the 
colon. This is done as follows : The bowels are emptied by a purga- 
tive or by enema. Then through a rectal tube connnected by 
cannula with a rubber tube and glass funnel J to i liter of warm 
water is allowed to run in and out of the colon by alternately rais- 
ing and lowering the funnel ; fresh water is always introduced until 
the return is clear. The washings are allowed to settle and exam- 
ined macroscopically and microscopically. We look especially for 
mucus in large or small shreds, pus, blood, and tissue particles. 
Their diagnostic value is evident. 

Colitis, one of the most common causes and sequelae of chronic 
constipation, can only thus be recognized. In this condition the 
colon proves to be tender on palpation, but so it is also in simple 
spastic constipation, where we often feel the sigmoid, descending 
or ascending colon as tender, firmly contracted cords which change 
form under our fingers. 



CONSTIPATION 333 

Temporary or prolonged diarrhea or the patient's assurance of 
one daily movement should not mislead us. Irritation of the mu- 
cosa by hard scybala may bring on hyperemia, serous secretion, 
liquefaction of the intestinal contents, and abnormal gas produc- 
tion, which all accelerate peristalsis (stercoral diarrhea). Or the 
feces accumulate and become inspissated in the pouches of the 
colon and a central canal remains patent through which a daily 
evacuation takes place. A thin varnish-like coating of mucus 
over hard scybala does not mean catarrh, but is simply a local 
irritative hypersecretion. 

Among gastric diseases ulcer, pyloric stenosis, hyperchlorhydria, 
and atony are most frequently associated with constipation, es- 
pecially atony. Hence the necessity of examining the motility 
and chemistry of the stomach. The coexistence of- gastric and 
intestinal atony is due to the same underlying causes. Hyper- 
chlorhydria is frequently accompanied by constipation ; the actual 
mechanism is not understood. We know from Strasburger's 
ingenious method of weighing intestinal bacteria (living and dead) 
that they are diminished in hyperchlorhydria. The latter may be 
a sequel of habitual constipation, probably induced by the habitual 
abuse of cathartics. 

Enteroptosis is easily recognized by the habitus enteroptoticus 
described above, by bimanual palpation of prolapsed kidneys 
(nephroptosis), by the detection of a stomach-splash in an abnor- 
mal location, and by gastric transillumination (gastroptosis), by in- 
sufflation of the colon with air or gas, or filling it with water for the 
purpose of detecting a prolapse of the transverse colon (coloptosis). 

The differentiation of atonic and spastic constipation is easy 
from the symptoms. Often enough the two conditions coexist, or 
spastic phenomena manifest themselves in the course of ordinary 
atonic constipation: attacks of colic in which the usual cathartics 
do not act at all or only in enormous doses and with great pain; 
cord-like contraction of the colon, which is tender; rectum empty; 
the stools as described above. Paul Cohnheim claims that almost 
every case of habitual constipation goes through the following 
stages; (a) atonic; (b) catarrhal; (c) spastic stage; (d) enteritis 
membranacea; (e) colica mucosa; (/) mucous diarrhea. This 
classification is somewhat schematic, but instructive and practical. 



334 MEDICAL GYNECOLOGY 

A diagnosis of habitual constipation is not complete without a 
diagnosis of the etiology. A painstaking anamnesis and examina- 
tion of the whole body will bring out the etiologic factors in most 
cases. 

Let us recapitulate the most important diagnostic hints : 

Do not overlook rectal and intestinal carcinoma. 

Learn to recognize fecal tumors. 

Remember the occurrence of stercoral diarrhea. 

Recognize the coexistence of constipation and intestinal catarrh ; 
weigh their interaction in each case. 

Remember Trousseau's dictum that about one-half of the gas- 
tralgias originate in the transverse colon. 

PROGNOSIS 

The prognosis as to life is good. No one ever dies of constipa- 
tion directly, but the sequelae (intestinal obstruction and peri- 
tonitis) may prove fatal. It is worthy of note that the three sur- 
gical diseases most commonly calling for major operations, ap- 
pendicitis, hernia, and hemorrhoids, are intestinal, and chronic 
constipation is frequently responsible for their development. Thus 
it is to be seen that habitual constipation is not a negligible factor. 

As to cure, the prognosis is doubtful. A permanent cure is 
feasible in some cases; i. e., natural action can be established 
and maintained where hitherto artificial means were constantly to 
be resorted to. But too often the disturbance recurs. Presuppos- 
ing an intelligent conduct of the case, success is dependent largely 
on the patient's means and her personal character. Failures and 
relapses are frequently the result of a want of perseverance. Too 
often the condition is neglected and only comes under systematic 
treatment after the drug-habit or enema-habit has become firmly 
established or after organic changes have taken place. Prognosis 
is affected by the duration of the trouble and the age of the patient. 
Most essential of all is intelligent and willing co-operation of phy- 
sician and patient. 

PROPHYLAXIS 

Prophylaxis ought to begin in the first year of life. The founda- 
tion for many a weak digestion is laid during that period. In- 



CONSTIPATION 335 

telligent nurses know how to coax infants into having their daily 
movements at regular hours. Children ought to be supervised as 
to that function. Boys and girls, especially of school age, must be 
impressed with the importance of the act and its regularity. They 
must be cautioned not to neglect the calls of nature. Girls ought 
not to wear corsets too early. With them the habitual use of purga- 
tives is especially disastrous and reprehensible. They should be 
brought up on a mixed diet and taught to drink water freely. 
These measures, the cultivation of regular habits, a common- 
sense mode of life, a common-sense dress, and avoidance of tight 
lacing are the best preventives of habitual constipation at all times. 
These measures must be insisted upon, especially in members of 
families where sluggish bowels are a family failing. 

The pregnant state, which offers a special predisposition for the 
development of constipation, must be managed with a view to the 
prevention of this disorder. Much can be done by proper diet, 
outdoor life, and abdominal binders. Intelligent management of 
the puerperal state, as outlined in another section, will preserve 
the intestinal functions or restore them should they become dis- 
ordered. 

We heartily wish to recommend here the following simple gym- 
nastic exercises, which ought to be commenced one week after 
delivery, provided the course of the puerperium has been perfectly 
normal. Patients lie flat on their backs and raise themselves to 
the sitting position without the aid of their arms and hands, and 
then gradually and slowly return to the recumbent position; the 
latter exercise must be done in stages during which the trunk is 
held through muscular action in various angles to the pelvis. It 
may be necessary to start with the latter exercise, in case patients 
are too weak to do the former first. The exercises are gradually 
increased up to ten to twenty times, two to three times a day. They 
can also be done against resistance. The change in the structure 
of the abdominal wall under these exercises is truly astonishing; 
from day to day we can feel the muscle bundles become broader 
and firmer and the interstices between them smaller. If this 
procedure is continued sufficiently long, the abdominal muscles 
may develop to such an extent that the wearing of a post-partum 
binder can be dispensed with. 



336 MEDICAL GYNECOLOGY 

Gynecologists ought to pay more attention to constipation. 
They see a great deal of it. Pelvic inflammatory disorders by 
inhibiting peristalsis may be responsible for constipation. Fre- 
quently enough constipation causes pelvic congestion. Physicians 
ought not to be satisfied with a prescription for a cathartic, but 
should treat their cases as outlined under the next heading, and 
they should not dismiss a gynecologic case from treatment before 
they have done their best to cure the existing constipation. 

The family physician must be, as in so many instances, the prin- 
cipal prophylactic agent. He must on all occasions warn his 
patients against the abuse of cathartics; he must combat the 
fallacious opinion that all sorts of minor ailments can be driven out 
by a good purge, or that the treatment of every acute disease must 
begin with a dose of salts. 

Hospital and dispensary physicians ought to awaken to their 
therapeutic sins in this respect and to their responsibility in foster- 
ing the most common of disorders of civilized man, constipation, 
by the indiscriminate and injudicious administration of purgatives. 

In dispensaries special therapeutic departments ought to be 
created where hydrotherapy, mechanotherapy, and electrotherapy 
are practised and where cases of habitual constipation are sent for 
special treatment, after their diet has been mapped out and faulty 
habits have been corrected by the attending physician, the latter to 
control the entire treatment. The creation of physico- therapeutic 
departments, while materially enhancing the value of dispensary 
treatment for all applicants, would especially benefit the large 
class of constipated patients. 



TREATMENT 

Drugs play a minor role. This must be the leading sentence. 
It is high time that physicians became imbued with the truth of 
this statement. The treatment consists of hygienic, dietetic, and 
mechanical methods, and where they can be ascertained, demands 
the removal of etiologic factors. Each case is a law unto itself. 
The following points apply to the average case of simple atonic 
constipation. 

1. Habit. — Patients should be told to keep regular hours, so 



CONSTIPATION 337 

far as possible, for rest, meals, and sleep, and above all, to go to 
stool at a certain fixed time every day. Normally, intestinal in- 
nervation is so constituted that the mechanism of defecation is 
set in motion once a day at about the same time. Hence the in- 
stitution of a stool-time is but natural. This idea is so simple that 
it is not sufficiently appreciated by physicians and patients. Every 
day at exactly the same time the patient should go to the toilet and 
try to have a movement. If the effort is ineffectual after a reason- 
able time, she should wait until the next day, even if she feels the 
desire during the day. If these efforts be futile on the second day, 
she should take at once an injection of lukewarm water. The 
same practice is repeated on the following days, only the water for 
the injection is taken at a colder temperature. This systematic 
repetition of the act, exactly at the same hour, usually brings on the 
desire at that particular time, and it is rare that this training fails 
of its purpose (Trousseau). 

The best time is after breakfast, because the ingestion of food 
into the fasting stomach incites intestinal peristalsis. For some 
people it may be more convenient to go to stool directly upon 
rising, after drinking a glass of water. Others may select, for 
reasons of expediency, any other time of the day. Patients with 
hemorrhoids do best to have their hour for defecation in the 
evening, when they have time to lie down afterward and permit 
the prolapsed and engorged nodules to recede and become degorged. 

2. Diet. — The natural treatment of all digestive disorders is 
dietetic. No case of habitual constipation can be corrected with- 
out a proper diet, but some by that alone. 

(a) Avoid all substances which tend to constipate, such as tea, 
cocoa, chocolate, claret, blackberries and blackberry cordials, 
whortleberries (all on account of their tannic acid content), po- 
tatoes in quantity, rice, thick gruels (except oatmeal), burnt flour, 
and certain kinds of cheese which form a tough curd in the in- 
testinal canal, (b) Select such substances as stimulate peristalsis 
either mechanically by the bulky residue which they leave behind 
or chemically or thermically. As a rule, a combined action is pro- 
duced, such as by cabbage, salads, or other fresh vegetables, beets, 
carrots, asparagus, turnips, pickles, celery, radishes, olives, onions, 
sprouts, spinach, tomatoes, bran-bread, Graham-bread, Pumper- 



338 MEDICAL GYNECOLOGY 

nickel. The active chemical agents are either present as constit- 
uents of these foods or are added to them before consumption, or 
are evolved during their digestion in the alimentary canal. They 
are organic acids (lactic, butyric, acetic, carbonic, tartaric, and 
malic, or the lower fatty acids), sugar, and common salt. These 
physiologic alimentary cathartics are represented by the following 
articles : 

Fruits, best given cooked or stewed and sweetened with sugar 
of milk, especially apples, prunes, figs, oranges, peaches, dates, 
grapes, grape-fruit, melons, jams, marmalades, treacle, honey, 
syrup, lemonade, cider, light white wine. 

Milk, which constipates a few people but purges many, especially 
when taken raw and with the addition of salt to prevent the forma- 
tion of a tough curd ; buttermilk; kumyss; matzoon; sour milk, 
prepared by spontaneous souring or by means of zoolak or of 
specially prepared lactic acid bacilli in the form of tablets; whey, 
prepared with rennet or cream of tartar. 

Carbonated waters, beer, and champagne. 

Salted foods, such as herring, sardellen, caviar, ham, smoked 
salted beef; condiments. 

Fats and oils act as lubricants, if they escape digestion, but 
principally by being split up into glycerin and fatty acids, some of 
which are volatile. 

Cold drinks act by their thermic effect, the cold being a strong 
stimulant to peristalsis. Cold water acts best on an empty stom- 
ach or at bedtime. 

All substances from which we expect a chemical effect act better 
when not given on a full stomach and when interchangeably given 
from day to day. 

From this large variety of anti- constipation foods and drinks 
we choose and combine those which seem best adapted to each 
specific case. Our choice must be governed by the circumstances 
of the patient, his tastes, his idiosyncrasies, his nutrition, the 
severity and duration of the trouble, the state of the digestive 
organs (hyperchlorhydria, atony of the stomach, tendency to 
flatulence), and by complicating diseases. Milk preparations and 
sweets are apt to give rise to flatulency. This wears off in time, 
or the patients get accustomed to it. But should it be excessive 



CONSTIPATION 339 

and troublesome, then we have to substitute the offending sub- 
stances by others on the foregoing list. Altogether, the proper 
diet is a mixed one with a restriction of animal food and 
a preponderance of carbohydrates and fats. Kohnstamm be- 
lieves that meat contains constituents which inhibit peristalsis, 
and for that reason he eliminates meat entirely from the diet of 
constipated patients. 

The grape-cure is used in certain European health-resorts 
with good effect for the relief of habitual constipation. Patients 
eat one pound of grapes (without the skins) the first thing in the 
morning, one pound before luncheon, and one pound before retiring 
— in addition to their regular meals. 

The lemon-cure acts similarly and is more feasible. Patients 
take the juice of two to three lemons in a glassful of sugar- water 
three times a day. The cure is suitable for the gouty and obese. 

The following is a diet list for a moderately severe case of atonic 
constipation : 

Glass of cold water with a pinch of salt sipped the first thing in 
the morning on an empty stomach. One-half hour later: 

Breakfast: Coffee with sugar and milk or cream; ham or bacon 
and a cereal breakfast-food; rye or Graham bread with plenty of 
butter and honey or jam or marmalade. 

Luncheon: Eggs or meat, vegetables, bread and butter; a glass 
of buttermilk or a dish of sour milk. 

Supper: Broth, meat, plenty of vegetables and relishes, compot 
(prunes and figs mixed), bread and butter; two hours later a glass 
of beer or ale. The beer may be taken with the supper and the 
compot before retiring. Water is to be taken freely between meals. 

Individuality plays a great role in the matter of diet. The in- 
testines of different individuals are amenable to different alimen- 
tary stimuli, and these must be ascertained in each case, which may 
at times require patient study and skilful experimenting. 

3. Kinesiotherapy (Exercise Treatment). — It is an old popu- 
lar belief that people of sedentary habits are particularly subject 
to constipation and to stasis of the abdominal and pelvic vessels. 
Exercise in the open air increases the activity of the circulatory 
and respiratory organs, promoting appetite and sleep and thus 
improving neuro-muscular and glandular functions. It has been 



34-0 MEDICAL GYNECOLOGY 

shown that by walking after meals the stomach empties itself 
more quickly. All outdoor sports, if not exaggerated, are of benefit 
to the constipated; some more, some less. Rowing is best; horse- 
back-riding, swimming, bicycling, and bowling come next. Indoor 
gymnastics may be substituted or added (Zander apparatus, row- 
ing machines). The German system of "Turning" is excellent. 
The following exercises are adapted for home use: Raising the 
body from the horizontal position on the floor to the sitting and 
slowly returning (Fig. ic6) ; bending the trunk forward and back- 
ward with knees stiff (Fig. 107); bending sideways (Fig. 108); 
rotating the trunk on the pelvis (Fig. 109); flexing the thigh 




Fig. 106. — Raising the body slowly from the horizontal position, with the legs held 
straight and horizontal. 

quickly and sharply against the abdomen (Fig. in) ; settling down 
(Fig. 112). Between these various acts breathing exercises are in 
place. The important point about these exercises is that they 
should be executed accurately, systematically, and steadily. They 
are done twice a day, upon rising and before retiring, from ten to 
twenty minutes. The physician ought to show them or they may 
be taught from books. Adults are only too prone to lose interest 
and either give up or do them in a slipshod fashion. 

Postural Treatment. — An adjuvant, in cases where the diffi- 
culty is in the rectum and pelvic floor, is the postural treatment. 
Such patients should be made to assume the crouching position 



CONSTIPATION 



341 



during defecation by sitting on a vessel placed on the floor or by 
crouching on a high footstool placed in front of the water-closet, or 
they may cross their legs alternately, one over the other, and lean 
forward while sitting in the ordinary position. The action of the 
levator ani, torn during childbirth, can be partly substituted by the 
following manipulations: The hand is applied to the pelvic floor 



1 *• S 



\ 


!\.S' 


/ 


'"{ 






s"' ' 


' N 


t 


_ j\ 


1 








\ 


>\ \ 



[/ J 




Fig. 107.^ — Bending the trunk forward from the body with the knees held stiff. 

between anus and coccyx, so that the anus lies between index and 
middle fingers, and upward pressure is exerted during the act of 
straining. 

Fecal accumulations in the rectum are very common in atonic 
constipation. They can be palpated from the outside in the depth 
of the anal recess and a little to the left of the median line. Pa- 
tients can be taught to feel these accumulations; they can at the 



342 



MEDICAL GYNECOLOGY 



same time be taught to make deep stroking passes from the tip 
of the coccyx on the left side toward the anus and thus express the 
hard masses (Ebstein). 

Massage. — The most important mechanical aid in the treat- 
ment of habitual constipation is massage of the abdomen. Its aim 





Fig. 1 08. — The body is bent sideways from 
the hips. 



Fig. 109. — The trunk is ro- 
tated on the pelvis. 



is not simply to squeeze out the intestinal contents (it can never 
do that) , but to excite contractions of the intestinal musculature and 
systematically train the intestines to normal action. Besides it 
improves intra-abdominal circulation. There are two forms of 
abdominal massage in use: 

1. The greased hands are carried in small circular pushing mo- 



CONSTIPATION 



343 



tions from the cecum along the colon to the sigmoid. In addition, 
the rest of the abdomen is manipulated in various ways (Fig. 113). 
2. The hands are held stiff, the finger-tips being applied over the 
region of the cecum. Slightly increased pressure is exerted until 
the bowel is caught firmly between the fingers and the posterior 
abdominal wall. Then slight vibratory pushes are made. After 




Fig. no. — Side-bending and body rotation com- 
bined. 



Fig. in. — The thigh is flexed 
quickly against the abdomen. 



one to two minutes the other parts of the colon are thus successively 
manipulated (Fig. 114). An attempt is also made to grasp the 
colon between the hands and lift it up (Fig. 115). Deep massage 
is applied to the flexures of the colon (Fig. 116). The small intes- 
tine is similarly handled. Finally, the whole abdomen is shaken 
with the flat of the hands. This form of massage is more dim- 



344 



MEDICAL GYNECOLOGY 



cult and exacting on account of the greater resistance which the 
abdominal walls offer in the beginning, but it is also more effective. 
Massage must be practised daily for fifteen to thirty minutes, 
best in the fasting condition or before retiring, and continued for 
at least four weeks, then every other day, then twice weekly, and so 
gradually discontinued. The principal point is to have it carried 

out by a skilful operator who has not 
merely a certain technic, but knows 
what she wants to do and what she 
can do in a special case. Therein 
lies the trouble with massage. Many 
practise it, but "few are chosen." 
There are too few physicians who 
have a thorough knowledge of mas- 
sage ; and still fewer who know how 
to do it. There is no reason why 
more of us should not learn it and 
rescue an important branch of thera- 
peutics from the hands of irrespon- 
sible individuals. 

For patients who cannot afford 
this form of treatment self-massage 
may be substituted. An iron ball 
weighing about 6 pounds, sewn up in 
flannel, is rolled over the abdomen 
along the course of the large bowel 
and around the umbilicus for five to 
ten minutes every morning under 
moderate pressure by the patient in 
the recumbent position. Or the pa- 
tient, while sitting and stooping for- 
ward, exerts slight pushing motions 
against her abdomen with the finger-tips in the same direction as 
with the ball. 

Massage develops and strengthens atrophic or overstretched 
abdominal muscles; although less efficiently than special gymnas- 
tic exercises. 

Vibration. — Vibratory treatment is based on the same rationale 




Fig. 112. — Settling down. 



CONSTIPATION 



345 



as massage. It is indeed an integral part of some forms of massage. 
But it is usually administered by means of special apparatus, 
so-called vibrators. The vibrations are given in short or long 
strokes and with variations of speed and duration. Thereby the 
effect is modified. Long-stroked vibrations of short duration 
increase muscular and neural excitability; they have a stimulating, 
tonic effect. Short-stroked, rapid, and prolonged vibrations 
diminish excitability and have a sedative calming effect. The 




Fig. 113. — With the hands held stiff, circular motions are made over the 
course of the colon and over the entire abdomen with the palmar surface of the 
tips of the fingers. 



former mode of application is indicated in ordinary atonic consti- 
pation. The parts of the apparatus which are applied to the 
body (vibratodes) are of various shapes, generally hollow metal 
balls. These are carried over the abdomen in the same way 
as the hands of the masseur or the iron ball, used for self -massage. 
The vibratode can also be applied in the rectum, and is then shaped 
like a hard-rubber bougie. 



346 



MEDICAL GYNECOLOGY 



Abdominal Supports. — For splanchnoptosis congenital or ac- 
quired, for pendulous abdomen, for hernia ventralis, a good ab- 
dominal binder should be worn. The object of the binder is 
to lift and support. It should be made of a material which is 
somewhat elastic but also resistant. It should retain its position 
under varying conditions. It must be fairly light and easily ad- 
justable and must not spoil the figure, an important item with 
women. A combination of corset and binder is given in the so- 




Fig. 



114. — By deep pressure the bowel is caught between the fingers and the 
posterior abdominal wall. 



•called Heath corset, a straight-front corset with elastic straps 
around the hips, which is made to fit tightly at that point, while it 
fits snugly at the waist and loosely above (Fig. 98). * 

A good supporter is the "Storm binder" (Fig. q6). 2 In cases 
of umbilical hernia an umbilical pad may be attached to the binder. 

1 Made by the Pomeroy Company, New York. 

2 Devised and made by Dr. Katherine L. Storm, of Philadelphia Pa. 



CONSTIPATION 



347 



Other special pads, such as the much vaunted kidney-pad for 
floating kidney, are worse than useless. 

A. Rose's method of strapping the abdomen with adhesive plaster 
is highly recommended (Figs. 117 and 118). It has been proved 
by transillumination of the stomach and by the .r-ray and bismuth- 
ingestion that these measures (Rose's plaster straps, Storm binder, 
-etc.) really lift a sunken stomach several inches. 



Electricity, 



-Electricity vies with massage in the treatment of 




Fig. 115. — The colon, especially the ascending and descending colon, is grasped 
between the thumb and fingers of both hands and lifted up. 



habitual constipation. It 
success. Cures have been 
the static-induced current 
most familiar with the old 
and galvanic currents, and 
current. Although there 
authors as to the effect of 
muscles in particular, the 



is used in all its various forms with 
effected by means of static- wave and 
and the sinusoidal current. We are 
stand-bys accessible to all, the faradic 
their combination, the galvano-faradic 
is some difference of opinion among 
electricity in general, and on unstriped 
practical results in cases of habitual 



348 



MEDICAL GYNECOLOGY 



constipation remain undisputed. Peristaltic waves have been ob- 
served under the application of either current, in people with thin 
abdominal walls and in hernial sacs. 

The currents are applied in various ways to suit indications. 
Usually one large electrode is placed in the lumbosacral region of 
the recumbent patient and another medium sized one is carried 
over the abdomen. In the region of the cecum it is applied with 
greater pressure and left for a minute; then it is carried along the 
colon to the sigmoid, where the same maneuver is repeated; then 




Fig. 1 1 6. — Deep massage of the flexures of the colon and the kidney region. 



circular or spiral passes are made around the umbilicus. Cur- 
rents must be strong enough to produce lively contractions of the 
abdominal muscles. These contractions, however, are not the 
only object of the application, as they prevent the penetration of 
the current. Hence the electrode is applied also away from the 
motor points with considerable pressure. At the end of a session 
we allow the current to pass between two electrodes of the same 
size placed over the hypochondric regions. Where the pelvic 
floor is weak, one electrode may be applied over the perineum. In 



CONSTIPATION 



349 



overdistention of the rectal ampulla or in prolapsus recti one 
electrode is applied in the rectum. The cathode has a slightly 
greater stimulating action wherever applied. 

For the faradic current a flexible metal sound covered with 
webbing up to the tip is used (Fig. 119). 



a, „-^ 



/ 



/ 



\ 



\ 



\ 



\ 



\ 



\ 



\ 



\ 



\ 



/ 



/ 



\ 



\ \ \ / / 
N y V \' 




Fig. 117. — Rose's bandage. A piece of rubber plaster, of the average size of 
thirty -four by twelve inches, is cut as shown by the dotted lines in B. The large piece 
a is applied as tightly as possible around the abdomen, drawing it well upward, the 
two ends meeting or overlapping at the spine. The plaster should not include the 
crest of the ilium, but should run closely along and above it. The support of the 
abdominal walls is made perfect by additional application of the two side-pieces of 
the plaster b, b, turned in a way as shown by A, extending from the hypogastrium 
over the inguinal and iliac regions, and reaching also to, or near, the spine. In 
applying the side-pieces we may employ considerable force. 



For the galvanic current we need the medium of water to pro- 
tect the rectal mucosa and evenly distribute the current. Boas' 
electrode is very suitable (Fig. 120). A substitute may be impro- 
vised as follows : A soft-rubber catheter with numerous small holes 



35o 



MEDICAL GYNECOLOGY 



is pushed over a copper wire electrode up to the tip, fastened, and 
then introduced into the ampulla, which has been previously filled 
with warm salt water. A current strength of 20 to 30 milliamperes 
is used. The patient ought to feel a marked prickling sensation 
in the rectum. 

The galvano-faradic current combines certain advantages. 
Here the induced current acts on organs which have been put into 
a state of increased excitability (katelectrotonus) by the galvanic 
current, thereby increasing the stimulating effect. Besides, gal- 




Fig. 118. — Rose's bandage. Most patients bear this plaster without complain- 
ing of irritation of the skin, even during the hot weather; a few suffer from itching, 
especially in warm weather, but not enough to require removal of the plaster; 
while a very few complain of eczema to such a degree that the plaster becomes un- 
bearable, and has to be removed after a week or two- instead of remaining on for 
five or six weeks, as in the majority of cases. In such instances we may protect 
the skin by first applying Dietrich's india-rubber plaster with zinc, and the ordin- 
ary rubber plaster on top of it. 



vanism refreshes the muscles and thus counteracts any fatigue 
and exhaustion which may follow strong faradization. 

The ordinary galvanic or faradic current can be transformed 
into a sinusoidal current by attaching the two wires from the 
office-battery and passing the current through the sinusoidal cur- 
rent machine. 

This consists of an insulated metal cylinder on which is wound 
a fine high-resistance wire. On either side of the cylinder are 
fastened two bars with sliding traveling contacts which are attached 
to a reciprocating device, driven by a small electric motor for those 



CONSTIPATION 



35^ 



who have the street current and a spring motor for those who have 
the battery current. The sinusoidal current has the following 
characteristics : 

The current of a given polarity increases from zero to a certain 



Fig. 119. — Flexible rectal faradic electrode. 



maximum, then drops back gradually to zero, when the polarity 
changes and a gradual increase and decrease of the current takes 
place, to be followed by an increase and decrease with the original 
polarity and so on. The strength of the current goes as far in 
one direction as in the other. 
The constant change of po- 
larity when using the gal- 
vanic current eliminates all 
electrolytic action; stimula- 
tion being the sole property 
of this kind of current. This 
current has no equal in its 
power to contract non-stri- 
ated muscle fiber; it is 
therefore without a rival in 
all atonic conditions of in- 
voluntary muscles. It is 
well to remember the nor- 
mal rhythm of the particu- 
lar organ under treatment. 
This current should not 
have more than ten to thirty 
alternations per minute. 

Electric treatment can, if 
necessary, be entrusted to 
intelligent patients, which 
is of advantage in some 
instances. Compared with self-massage, self-electricity is more 
valuable. 

Hydrotherapy. — We use general and local, internal and ex- 




Fig. 120. — Boas' rectal galvanic electrode. 



352 



MEDICAL GYNECOLOGY 



ternal hydrotherapy in habitual constipation. We have already 
mentioned the importance of drinking water freely. We may add 
that gastric lavage or douching with normal salt solution (or 
Wiesbadner Kochbrunnen) has been recommended for the cure of 
this trouble. From \ to 1 P int * s allowed to run in and out by 
alternately raising and lowering a funnel connected with a stomach- 
tube. This procedure excites active intestinal peristalsis, and if 
practised daily for several weeks may accomplish permanent re- 
sults. It is especially indicated in complicating nervous anor- 
exia, nervous anacidity, and subacidity. 

The introduction of water into the lower bowel is one of the most 




Fig. 



-Attachment to be connected with any battery for the production of the 
sinusoidal current. 



popular theraupeutic measures. It is performed in various ways 
and is easily modified according to the end in view. We may 
use -small or large quantities of water of varying temperatures; 
in short or long intervals; under high or low pressure; in different 
positions of the patient and with various additions, as salt, soap, 
glycerin, oil. The most common indication is coprostasis, acute 
or chronic. Here the injection softens the feces, thereby facilita- 
ting their expulsion, and excites peristalsis of the lower bowel. The 
best and simplest form of an evacuating enema for an adult is the 
injection of about one pint of water at 8o° to 95 F. with the addi- 
tion of a little soap, administered from a fountain syringe in the 



CONSTIPATION 353 

recumbent position and retained as long as possible. These in- 
jections may be used over long periods of time without doing any 
harm. Or the patient injects 6 to 10 ounces of warm water with a 
teaspoonful of green soap or glycerated soap and retains it over- 
night, whereby hardened masses are softened and peristalsis of 
the lower bowel is greatly excited. 

Of external local applications we employ abdominal douches, 
compresses, and sitz-baths or hip-baths. Sitz-baths or hip-baths 
powerfully influence the innervation of the abdominal and pelvic 
organs and the capacity of the abdominal vessels, the largest 
blood-reservoir of the body, the filling of which to a great extent 
controls the general circulation and blood-pressure. 

Cold or very hot hip-baths contract the abdominal vessels, 
driving the blood to other parts, as evidenced by congestion of the 
head, increase of axillary temperature, lowering of the rectal tem- 
perature. If this thermic irritation lasts but one to three minutes, 
prompt reaction ensues, that is, active hyperemia of the abdominal 
organs takes place. 

Short, cold hip-baths from 50 to 68° F. are therefore indicated 
in all conditions of the abdominal organs which are due to anemia, 
venous stasis, motor and secretory insufficiency, torpid metabol- 
ism; for instance, in atonic constipation. 

Abdominal compresses, in the shape of wet dressings (Priess- 
nitz compress, Neptune's girdle) (Fig. 105) worn overnight, allay 
the manifold unpleasant sensations which interfere with the com- 
fort or sleep of patients suffering from organic and functional 
gastro-intestinal disorders. 

A Scotch douche, i. e., alternating hot and cold, jet and fan 
douche on the abdomen, is a powerful stimulus to peristalsis. 
The same effect is produced by the ether-douche (Boas): once 
or twice a day for about five minutes the abdomen is sprayed 
from an atomizer with 100 c.c. pure sulphuric ether. 

All these local applications are very advantageously combined 
with general hydriatic procedures. Thus the short, cold hip-baths 
are preferably followed by a douche of gradually reduced tempera- 
ture or a Scotch douche on the abdomen, and later by a stimulat- 
ing douche to the entire surface. Affusions of the abdomen of 
cold water from a good height are preferably combined with 
23 



354 MEDICAL GYNECOLOGY 

half-baths of 85 to 8o° F. It is positively established that the 
best effects of hydrotherapy are brought out by applications to the 
entire surface, viz., its effect on circulation, respiration, and in- 
nervation, over-secretion, and excretions. 

General hydrotherapeutic procedures find their greatest field of 
usefulness in chronic disorders of the gastro-intestinal tract, es- 
pecially the functional ones, be the latter a manifestation of 
neurasthenia or hysteria, or the primary cause of the disturbance 
of the cerebrospinal centers. Such measures are graduated 
douches (circular, jet, and fan douche) of one to two minutes' 
duration and 30 to 40 pounds' pressure, preceded by artificial 
warming of the body and followed by friction — best carried out 
in special institutions. 

For home use the following measures are indicated : 

Ablutions by means of a rough towel, a bath glove, or the hand 
with water at 8o°, reduced gradually two degrees each day down to 
6o° ; affusions with water at the same temperature ; the drip sheet 
from 70 to 50 , followed by a half-bath from 85 to 8o°. We 
employ one or other of these applications, according to whether 
symptoms of irritation or depression predominate in the particular 
case and whether the patient is poorly or well nourished, anemic 
or plethoric. The great advantage of hydrotherapy is that it can 
be so modified as to suit almost any case and condition where it is 
at all indicated. 

Spastic Constipation. — This brings us down to a brief con- 
sideration of spastic constipation. Where the spastic phenomena 
are predominant and recur frequently, the treatment must differ 
in many essential points from the one hitherto outlined for the 
atonic form. Everything must be done to allay spasm and soothe 
an overexcited nervous system. Cold hydriatic procedures are 
contraindicated. Warm full baths, or sitz-baths, or a hot-water 
bag on the abdomen, are very acceptable; also injections of warm 
water with the addition of aromatic substances, or the drinking 
of large quantities of hot peppermint, fennel, or camomile tea. 
Electricity and massage are out of place. The diet should not 
contain coarse substances, which act mechanically through a bulky 
residue, but chiefly such as exert a chemical action. 

Much rest is essential for these cases, even resting in bed. A 



CONSTIPATION 355 

change of scenery is often of great benefit. Sanatorium regime 
generally surpasses home treatment. 

Oil enemata find here their greatest usefulness, more so than 
in the ordinary form, where they are also largely used, and justly 
so. About 8 ounces of warmed pure oil (olive or the cheaper 
sesame oil) are introduced into the bowel by means of a rectal tube 
and funnel or a hard-rubber hand syringe (4 ounces) applied by the 
patient himself or by an attendant (Fig. 107). The patient should 
lie on the back or the left side with the head low and the pelvis high, 
and not rise for some time after the injection, in order to give the 
oil an opportunity of evenly distributing itself over the colon. 
(It has been found at operation oozing out from a perforated ap- 
pendix.) It is therefore best given after retiring; every night 
for two weeks, then every other night for one week, then every 
third night for one week, then twice a week, then gradually dis- 
continued. If 8 ounces act too strongly, the quantity should be 
reduced; if not acting sufficiently, it is increased. Should there 
be no movement after breakfast the following morning, a small 
injection of warm soapsuds is administered. There will be no 
soiling of the bed if the injections are given lege artis. Where 
one is not sure of that, we advise the wearing of an anal pad held 
in place by a T-binder. 

In spastic constipation drugs are frequently needed, not the usual 
purgatives but rather sedatives : for the local effect belladonna and 
opium, for the general effect bromids. The former are given per 
os or as suppositories, alone or combined, in medium or small 
doses several times a day. They regulate disordered innervation so 
that movements take place without other measures being resorted 
to (cj. lead-colic). We have also heard patients assert that under a 
course of bromids bowels formerly sluggish resumed natural action. 

Suggestion plays a great role in the treatment of the sick. We 
have already spoken of the necessity of the formation of a regular 
stool habit. This is psychic treatment. In very obstinate cases 
of habitual constipation which have resisted all therapeutic en- 
deavors, hypnosis has effected cures. It is indeed regrettable 
that hypnotism is practised by irresponsible people, and that so 
much mystery and charlatanism are being attached to it. 

Psychotherapy is in its infancy in this country, and only recently 



356 MEDICAL GYNECOLOGY 

has it been taken up by physicians. We do not doubt that many 
cases of habitual constipation would be amenable to this treatment. 

Drugs. — Medicinal treatment is considered last because it does 
not cure the atony of the intestinal musculature nor regulate the 
faulty innervation of the colonic and rectal peristalsis. It is 
merely palliative. The guiding principle should be to do without 
cathartics wherever possible. We do not absolutely oppose the 
use of drugs, but we advise their employment only on good in- 
dications. Let us bear in mind two simple facts: First, that 
there is no fundamental difference between the laxative effect 
of stewed prunes from the kitchen and that of tamarinds or 
manna from the drug-store. Second, not a few individuals take 
their daily dose, year in, year out, with good effect and without 
harm to the system or aggravation of their intestinal sluggishness. 

Purgative drugs are indicated in the treatment of habitual con- 
stipation : 

(a) In the beginning of a systematic cure, in the case of drug 
habitues. 

(b) Where the hygienic, dietetic, and mechanical treatment is 
ineffective. 

(c) Where such treatment cannot be carried out. 

(d) In the aged, whereas in children and adolescents their 
habitual use cannot be too strongly condemned. 

(e) In complicating diseases, chronic heart disease, arterioscle- 
rosis, kidney disease, diabetes, plethora, during pregnancy and 
acute intercurrent conditions requiring rest in bed. 

Whenever compelled in these cases to use drugs, we should 
observe the following rules : 

i. Always select the mildest aperients; avoid drastics. 

2. Find out the proper dose. 

3. Use them intermittently; i. e., try from time to time to omit 
them and get along with the physiologic methods. 

4. Change off between the various suitable remedies so as to 
avoid habituation and an accumulation of unpleasant by-effects. 

5. Select those which produce soft, abundant movements with- 
out inconvenience. 

6. Give them in a pleasant convenient form. 

7. Combine several of them if you see fit. (Single drug prescrip- 
tions may be highly scientific, but are often impractical.) 



CONSTIPATION 357 

The following drugs are at our disposal for prolonged use: 
Castor oil, rhubarb, senna, aloes, podophyllin, cascara, sulphur, 
salts, and a few modern preparations, such as purgatin, purgen, 
exodin, regulin. Their choice is governed by their pharma- 
cologic action and by the requirements of the case. They all act 
ultimately by stimulating peristalsis. Occasionally and for special 
reasons calomel or one of the drastics may become necessary, like 
jalap, colocynth, scammony. 

Oleum ricini (i dram to i ounce) is perhaps the mildest of all, 
tasteless when given in large soft capsules, and rarely fails. 
It passes the stomach unchanged and is split up and saponi- 
fied by the bile and pancreatic juice; a part of it escapes unchanged 
into the lower parts and acts as a lubricant. It can be given even 
in complicating catarrhal conditions and is especially indicated 
where constipation and diarrhea alternate and colic is frequent. 

1$. Ol. ricini. 

Syr. rhei. aromat aa 5 j (3°-°) 

S. — 3j (4-o) ever}'' three hours. 

Rhubarb, senna, and cascara contain as active principle cath- 
artin or cathartinic acid, an acid colloid glucosid which is split 
up by the pancreatic juice into chrysophanic acid and emodin, 
both anthracen-derivatives. The former is excreted in the urine 
and gives rise to a red or, in the case of cascara, a stronger yellow 
color on addition of an alkali. 

Rhubarb: Some patients chew a piece of the root daily for 
indefinite periods with good effect. The drug contains a bitter 
principle to which its action as a stomachic is due, and a special 
tannic acid which accounts for its constipating after-effect. It is 
often combined with other aperients, like castor oil, aloes, or salts. 

Pil. rhei co. (U. S. P.) contains about gr. ij (0.13) of rhubarb, 
gr. iss (0.1) of aloes. Two are taken at night. It acts in ten to 
twelve hours. 

Rf. Pulv. rad. rhei O j (30.0) 

Sod. sulph oj (3°-°) 

Or— 

1$. Pulv. rad. rhei § j (3°-°) 

Potass, bitart oij (60.0) 

Sulphur, sublim o ij (60.0) 

S. — 5j at bedtime. 

Our domestic rhubarb-plant possesses no laxative properties. 



358 MEDICAL GYNECOLOGY 

Senna: Acts in three to four hours when given alone in full 
doses. It is the active agent in most of the popular teas and 
nostrums. 

Pulvis Glycyrrhizce Compo situs (U. S. P.) is used extensively. 
We prefer to give it to patients suffering also from chronic bron- 
chitis and emphysema. It was formerly used as an expectorant 
on account of its containing licorice and sulphur. Dose, 5j (4.0). 

Syrupus Senna Aromaticus (N. F.) and Syrupus Senna Com- 
positus (N. F.) are pleasant and appropriate. A few senna 
leaves placed in a muslin bag and stewed together with prunes 
impart to the latter its cathartinic acid and materially enhance 
their laxative action. 

Injusum Senna Compositum (U. S. P.) contains, besides senna, 
twice the quantity of manna and magnesium sulphate, and is only 
adapted for occasional strong action, e. g., in the lying-in period, 
when it is very effective in 2-ounce doses. 

Cascara Sagrada: at present perhaps the most popular laxa- 
tive prescribed by physicians. It acts mildly during the night. 
The dose of the fluidextract (5j) can be easily regulated ac- 
cording to the effect produced, a great advantage when we wish 
gradually to wean an habitue. The solid extract is given in 2- 
to 5-grain pills (0.12 to 0.3 ). 

Aloes: is an ingredient of almost all patent pills and of many 
of the officinal preparations. 

Pilule Aloes (U.S. P.). 

Pilulae Aloes et Mastiches (U. S. P.). 

Pilulae Aloes et Myrrhze (U. S. P.). 

Pilulae Aloes et Podophylli Compositae (N. F.). 

Pilulae Aloini Compositae (N. F.). 

Pilulae Aloini Strychninae et Belladonnae (N. F.). 

Pilulae Aloini Strychninae et Belladonnae Compositae (N. F.). 

Pilulae Laxativae Post Partum (N. F.). 

The multiplicity of these officinal pills testifies to the good 
qualities of aloes and its active principle, aloin. They act ex- 
clusively on the large bowel in from twelve to fifteen hours. Bile 
seems to be necessary to bring out the effect. There is apparently 
no habituation and no increase in dosage necessary. In full doses 
aloes produces hyperemia not only of the lower bowel but of the 



CONSTIPATION 359 

pelvic vessels, which precludes its employment during pregnancy 
and the puerperium and permits of it only in small doses during 
menstruation. 

Podophyllin: A reliable purgative in doses of gr. \ (0.015), 
laxative in doses of gr. -^ (0.006) as resina podophylli U. S. P. 
It is rarely used by itself. It is a good cholagog. 

Sulphur, given in dram doses, in the form of sulphur lotum, 
sulphur precipitatum (milk of sulphur), sulphur sublimatum 
(flowers of sulphur), or as the popular sulphur and molasses, 
or combined with salts, e. g., cream of tartar. When finely 
subdivided it passes the stomach unchanged and is transformed in 
the intestines into hydrogen sulphid and then into potassium and 
sodium sulphid, strong peristaltic stimulants. But as this change 
is very gradual there is no purgation ; the feces are simply rendered 
soft. Hence its popularity in hemorrhoidal troubles. 

It appears from the above prescriptions that combinations are 
much in vogue, that there are enough officinal formulas to suit 
almost any condition, and that physicians have, therefore, no 
justification or excuse for prescribing patent or proprietary prep- 
arations if they do not want to make combinations of their own. 

The following drugs are frequently combined with purgatives 
proper : 

Strychnin sulphate (gr. -^ to -g^) or extract of nux vomica, up 
to J grain in one pill, for its general and local tonic effect. 

Atropin sulphate (gr. yj^ to -V) or extract of belladonna up to 
J grain, or extract of hyoscyamus up to 1 grain, to combat spasm 
or prevent griping. 

Physostigmin salicylate (gr. ^-) or extract of physostigma (up 
to gr. J), to prevent or combat meteorism. 

Pulvis capsici up to gr. 1, to stimulate gastric secretion. 

Asafetida, myrrh, mastiche, in 2-grain doses, or the various 
ethereal oils in drop doses to prevent flatulence. 

As previously mentioned, rhubarb, senna, rhamnus, and aloes 
contain anthracen-derivatives as active agents. An attempt has 
lately been made to manufacture synthetically anthracen-deriva- 
tives with purgative properties. The result of these endeavors is 
purgatin or purgatol, exodin, and purgen. Purgatin, a light yellow 
powder, insoluble in water, produces good evacuations without 



360 MEDICAL GYNECOLOGY 

griping, in twelve hours if given in doses of 8 to 30 grains (0.5 to 
2.0); it colors the urine a Burgundy red. 

Exodin, a greenish-yellow tasteless powder, insoluble in water, 
made in 7^-grain (0.5) tablets, is highly lauded by Ebstein as an 
adjuvant to oil-enemata in fecal impactions. 

Purgen, the well-known indicator phenol-phthalein, is sold in 
tablets of 0.05 to 0.1 to 0.5 g.; it colors the feces red. 

Salts: Sulphate of soda (Glauber's salt), sulphate of magnesia 
(Epsom, bitter salt), phosphate of soda, oxid and carbonate of 
magnesia, bitartrate of potash (cream of tartar), tartrate of potash 
and soda (Rochelle salts), Sal Carolinum factitium (N. F.) (Carls- 
bad salts). 

They stand between the mild aperients, calomel and castor oil, 
on the one hand, and the drastics on the other. They are ab- 
sorbed with great difficulty from the stomach and intestines. 
They hold the water in which they are dissolved and prevent its 
absorption. The contents of the small intestine arrive in the colon 
in the fluid state and here escape inspissation, as the greater part 
of the salts remains unabsorbed and passes out. They further- 
more mildly stimulate the intestinal mucosa and thus reflexly ex- 
cite peristalsis. They should therefore be given diluted, preferably 
in the form of the natural mineral waters. They should not be 
given to bed-patients for long periods because with enforced rest 
the stomach does not empty itself promptly, and the salts are 
retained and depress the secretory functions of the stomach. 

For systematic use Glauber, Epsom, and Carlsbad salts are best 
administered in the fasting state, followed by a walk or some 
exercise, which accelerates their action. This is the common 
practice at health-resorts. These drinking- cures do not cure, they 
do not affect the underlying condition of habitual constipation, 
they are merely palliatives. In sending our well-to-do patients to 
Marienbad, Karlsbad, Tarasp, Kissingen, and Saratoga, we desire 
the,m to reap the added benefits of the many coincident factors of 
such a cure. 

Lean and weakly individuals, old people, convalescents, lying- 
in women, should not use the "middle salts" for prolonged periods, 
because with the accelerated passage of the intestinal contents 
much water and nutritive material passes out and is lost. Salts 



CONSTIPATION 361 

and mineral aperient waters are better adapted for fat or plethoric 
individuals, for whom this incidental effect is rather an advantage. 
The various salts are selected according to their additional phar- 
macologic properties which may be desirable in a special case of 
habitual constipation. Thus, magnesia usta and carbonica are 
given when we wish to neutralize a surplus of hydrochloric acid in 
the stomach; cremor tartari, when we wish a mild diuretic action; 
phosphate of soda for its action on the liver, and for its supposed 
inhibiting action on the symptoms of Graves' disease. The sul- 
phate of sodium and magnesium carry out of the system a great deal 
of water, not only the water needed for their own solution but also 
that present in the intestinal tract, and are therefore indicated in 
congestion of the abdominal viscera and in inflamed hemorrhoids, 
as well as in renal insufficiency (vicarious action). They are 
supposed by some to have a specific antitoxic effect on intestinal 
autointoxications, a still unproved hypothesis. After all that has 
been written on the subject, one fact stands out prominently, 
namely, that a good purge is the best intestinal antiseptic. 

Magnesium sulphate in 15-grain doses, together with 3 drops of 
aromatic sulphuric acid or dilute hydrochloric acid, every two or 
three hours, is a favorite remedy in lead poisoning, in uncinariasis, 
and in dysentery. 

Carlsbad salts are composed of sodium chlorid 18 per cent., 
sodium bicarbonate 36 per cent., sodium sulphate 44 per cent., 
potassium sulphate 2 per cent., a happy combination which fulfils 
various indications. Being devoid of irritating properties, they 
can be given in gastric ulcer with hyperchlorhydria for their antacid 
effect; but they are especially indicated in catarrhal conditions of 
the intestinal tract, which are not infrequently associated with 
habitual constipation, and especially in catarrh of the duodenum 
and of the large bile-passages. This explains their helpful action 
in catarrhal jaundice and in cholelithiasis (indirect cholagogs). 
Their popularity in gout and diabetes is due to their "salt" and 
"alkali" effect, which are supposed to increase the oxidation- 
processes in the system. 

Nearly all salines can be given in the form of effervescing 
solutions whereby their palatability is improved and their purga- 
tive effect enhanced through the action of the carbon-dioxid gas. 



362 MEDICAL GYNECOLOGY 

Regulin and pararegulin are preparations introduced by A. 
Schmidt for the regulation of sluggish intestinal action, due to 
an unusually vigorous digestion and assimilation (cf. Etiology). 
Regulin is agar-agar with 20 per cent, cascara extract; it is non- 
absorbable, swells up in the intestinal canal, and acts principally 
by its bulk and by its retention of water. Pararegulin is liquid 
paraffin with 10 per cent, cascara extract, given in teaspoon doses. 

The rationale of such popular remedies as vaselin, linseed, or 
the French grains de lin de Jarin is based on the same principle. 

Yeast, in the shape of brewers' yeast, in compressed cakes, or as 
cerolin (yeast fat) in 2-grain pills, has been recommended for habit- 
ual constipation, especially when it is accompanied by acne or 
furunculosis. 

Small doses of pure cultures of coli bacilli in capsules have 
also been recommended, on the supposition that the bacterial 
flora, when made sufficient, produces the proper amount of fer- 
mentative and putrefactive substances necessary for natural peri- 
stalsis. A similar idea underlies MetchnikorT's plan of gradually 
supplanting the ordinary intestinal bacteria by lactic acid bacilli. 
This may be brought about by the prolonged daily consumption of 
sour milk. 

The rectal application of drugs deserves special consideration. 
We have already mentioned the use of enemata containing salt, 
soap, glycerin, oil. We have discussed oil-enemata. Boas re- 
commends instead an enema consisting of 8 ounces of water, a 
small amount of baking soda, 2 tablespoonfuls of cod-liver oil, and 
2 tablespoonfuls of castor oil, the whole well emulsified. Glycerin 
is used extensively either in suppositories or, if a stronger or more 
certain action is required, in tablespoon doses by means of a special 
syringe (Fig. 122). Glycerin acts as an irritant to the rectum on 
account of its hygroscopic properties. Magnesium sulphate, dis- 
solved in water, is given per rectum alone or with glycerin, oil, soap, 
or oxgall. 

Aloin (gr. 6), cathartin (gr. 8), colocynthin (gr. J), citrullin 
(grain J), dissolved in a little water or dilute alcohol or glycerin 
and injected into the rectum (micro-clysters), are said to produce 
prompt evacuations even in obstinate cases. These drugs are 
expensive, except aloin, which may also be given in suppositories. 



CONSTIPATION 363 

For prolonged use only pure oil or emulsions of oil and perhaps 
of glycerin are approved. 

Flatow has recommended the insufflation of i dram of boric acid 
into the rectum by means of a powder-blower; this is worthy of 
trial. The drug can also be given in the form of suppositories of 
15 to 45 g rains (1.01:03.0). 

Rectal bougies, 1 foot long, of hard rubber with a central channel, 
are also used for the relief of habitual constipation. They me- 
chanically excite rectal peristalsis and overcome sphincter spasm. 
Hence their indication is limited. 

Old hardened masses sometimes have to be taken out of the rec- 
tum with the fingers or by specially constructed spoons or scoops. 

The operative removal of hypertrophic rectal folds is merely 
mentioned for completeness' sake. If they really do cause con- 



Fig. 122. — Rectal syringe for small glycerin and medicated enemata. 

stipation, it is a secondary or symptomatic form and does not 
strictly belong to our subject. 

Resume. — What measures shall we use in a specific case of con- 
stipation ? This depends entirely upon the nature of the case and 
on special circumstances We must individualize. A mild case in 
a young person may be cured by the correction of faulty habits and 
the institution of a proper diet. Gymnastics are next in order. 
Then a course of oil injections should be tried. 

More severe cases require, in addition, massage and electricity. 

It does not depend so much upon the method which is used as 
upon its methodic and prolonged employment. 

In obstinate cases we combine dietetic and mechanical means 
with hydrotherapy. We employ drugs only on the strictest in- 
dications. It is through the choice and combination of the proper 
measures that skill, experience, and medical instinct triumph. 



GONORRHEA IN CHILDREN 

Vulvovaginitis. — A purulent vulvovaginitis is not very rare in 
children. It is due, in the vast majority of cases, to the gonococcus. 

On inspecting a specific case there will be seen a profuse yellow- 
green discharge, which accumulation is greatest in the upper 
portion of the vulva and about the clitoris, in which area the dis- 
charge is also thicker and drier. The vulva itself, external to the 
large labia, is red, inflamed, and edematous, pitting on pressure. 
The main irritation is in the immediate circumference of the hymen, 
on the inner lining of the small labia, and on the perineum and 
fourchet. The sulci between the smaller labia and the future labia 
majora are much affected, being of a very dark red color, often 
with a deep bluish tinge. The vagina is generally involved. If 
treatment be devoted mainly to the vulva alone, improvement is 
therefore relatively slow. The opinion of many that the specific 
form is simply a vulvitis and not a vaginitis is decidedly wrong. 
While this is true in some cases, it is by no means the rule, as I 
have several times disproved by first washing the vulva and outer 
end of the vagina thoroughly and then observing the expression of 
pus from the vagina when the child cried or resisted efforts at 
treatment. 

The main evident lesion in gonorrheal vulvovaginitis is the 
inflammation immediately about the hymen, on the inner surface 
of the labia, and on the perineum. Frequently the cutaneous 
covering of and about the external genitalia is likewise affected. 
No matter how thoroughly the deeper vulvar lesions are treated, 
unless the entire skin periphery be likewise treated secretion will 
continue. The red, irritated character of the skin covering of 
the vulva is not due alone to irritation by the secretion, but to an 
actual destruction by the gonococci of the superficial layers of the 
epidermis. During the acute inflammatory stage the area sur- 
rounding the clitoris is least affected. 

Etiology. — Infection may come from contact with linens, 

3 6 4 



GONORRHEA IN CHILDREN 365 

towels, and sponges used by adults or children suffering from 
gonorrhea. In hospitals infection of children in the wards readily 
takes place in this way. Probably a frequent source of contamina- 
tion in hospital wards is furnished by the fingers of nurses who 
attend to an infected case and then, without sufficient precaution, 
arrange the toilet of the next child. The use of the same thermome- 
ter on several children in succession may also be the source of 
infection, for the thermometer is probably often passed over the 
vulva or even into the vagina in an attempt to take the rectal 
temperature. Care is necessary, in the first examination, to deter- 
mine if any attempted violence has produced local lesions beyond 
those of the infection — a factor which often explains the etiology. 
It is by no means easy to determine this fact, for penetration of 
the vagina need not occur. An attempt may have been made 
without injury or penetration, yet producing infection. A method 
which has served me, however, is the irrigation of the hymen 
with a large stream of water under mild pressure. The normal 
hymen is then brought into undulation and its margin is distinctly 
outlined. Any tears or lesions will be evident as irregularities or 
interruptions in the normal unbroken edge of this structure. 

Histopathology. — When gonococci grow on a mucous mem- 
brane they pass down between the epithelial cells, down to the 
connective tissue. There is a decided exudation of leukocytes 
from an extensive periphery into the connective tissue and through 
the epithelium. There is a vast difference depending on the charac- 
ter of the epithelium. In adults the urethra and cervix are readily 
infected because the cocci pass down easily between the cells 
arranged in palisade form. The vagina in adults is but slightly 
involved, because the vaginal epithelium is hard, dry, not arranged 
in palisade form, and therefore not readily entered. In the case 
of squamous epithelium, the softer and thinner it is, the more 
easily does the gonococcus invade it. That is why the tender 
covering of the vulva and vagina in children is easily invaded. 
Mandl found in sections made through the vaginal mucosa in a 
case of gonorrheal vaginitis: (i) surface epithelium gone; (2) all 
the epithelium gone in spots; (3) gonococci entering into the 
epithelium in rows and bands ; (4) the gonococci very deep in the 
tissue in spots and extending beyond the epithelial limit. Though 
the gonococci were generally in the superficial connective tissue, 



366 MEDICAL GYNECOLOGY 

in certain areas they were deeply embedded. The granular 
character of the vagina, in the gonorrheal vulvovaginitis of children, 
makes it evident that the pathology of the lesions is the same as 
in this severe case in adults. 

Examination of the Vagina. — Owing to the admirably re- 
flected light of the Ferguson speculum, I have devised a smaller 
speculum on the same plan, which is used for the same purpose 
in children. In them the vagina is long and of a curved course. 
It is remarkable how distinctly the color and the character of the 
vaginal lining may be seen through the small speculum, and the 
tiny cervix, with its tiny opening, can be distinctly brought into 
view. In this way too, quite naturally, applications of fluid or 
the use of a swab may be carried out in the same manner as in 
adults and a vaginal bath with any desired liquid may be given 
with the greatest of ease, limiting its action completely and pre- 
venting any undesired irritation of the vulva, perineum, vestibule, 
or urethra. On the use of the small speculum (Fig. 39) the red 
and inflamed character of the vaginal lining and the erosion of the 
tiny cervical os and the presence of cervical pus are very distinctly 
recognized. 

Involvement of the anus and rectum may take place. In 
some cases purulent secretion is found exuding from the anus and 
examination shows the presence of gonococci, with involvement 
of the rectum. Ulcerations result, often accompanied by the 
passage of blood, on the basis of which the diagnosis of proctitis 
is made. In other instances the lesions are of a more acute charac- 
ter. Minute fissures are present in the anal margin, causing 
pain and the passage of blood on defecation. 

Condylomata. — Continued irritation of the tissues leads to 
the same local anatomic lesions as occur in adults. Condylomata 
may be found on the perineum, on the large labia, and especially 
on the skin surrounding the clitoris, which in children is relatively 
large and thick. Condylomata may also be found in the neighbor- 
hood of the anus. 

Involvement of the Urethra and Bladder. — The urethra is 
not rarely involved in the gonorrheal process. That the bladder 
may be involved is shown by a case of purulent cystitis in a nine- 
year-old child, in which Wertheim found only gonococci. Gono- 
cocci were obtained in the cultures made from an excised piece of 



GONORRHEA IN CHILDREN 367 

the bladder mucosa. Microscopic examination of the specimen 
showed: (i) gonococci between the epithelial cells; (2) gonococci 
extending in rows into the subepithelial connective tissue and lying 
almost entirely extracellular; (3) the surface of the mucosa covered 
with fibrin layers; (4) gonococci in the blood-vessels. 

The uterus, tubes, and peritoneum may be involved in 
children. Through upward extension of the gonococci there may 
occur purulent involvement of the tubes, and pus is then poured 
out into the peritoneum, producing pelvic or even a general perito- 
nitis. Such cases in children of five, six, seven years of age and 
older are generally diagnosed as appendicitis. In every case of 
peritonitis in female children a vulvovaginal discharge should be 
looked for and a microscopic examination should be made. Good- 
man says: "Wertheim noted that peritonitis produced by the 
gonococci is accompanied by a greater exudate than that produced 
by other organisms. A child thus affected becomes feverish and 
looks ill. The temperature is generally not high, ranging between 
ioo° and 102 . The pulse may be as high as 140. There is often 
vomiting and abdominal pain. The abdomen is unusually dis- 
tended and tympanitic. No tumor can be felt. The rigidity of 
the recti is not marked. The picture is that of a general peritonitis, 
but to the clinical eye it does not carry the same conviction of 
severity as noted in severe appendicitis or intussusception. Some 
observers, however, mention the sharp and intensive onset and the 
serious aspect. The intestines are distended and injected. There 
is seropurulent fluid, there is pus in the pelvis, there are accumula- 
tions of lymph on some coils of the intestines." A diffuse gonor- 
rheal peritonitis generally progresses favorably, with palliative or 
symptomatic treatment. Operation may be deemed necessary if 
the severity of the onset suggests a mixed infection. In a collec- 
tion of eighteen cases of diffuse general gonorrheal peritonitis in 
which the gonococci were found on operation (collected by Dr. 
Chas. Goodman) the mortality was two cases. In the mixed 
infections there may be involvements of the lung, such as broncho- 
pneumonia or empyema, but these do not occur with pure gonor- 
rheal peritonitis. 

In other cases closure of the abdominal end of the Fallopian 
tubes takes place and varying degrees of pyosalpingitis may result. 
A not infrequent sequela of the milder extension to and involvement 



368 MEDICAL GYNECOLOGY 

of the peritoneum and ovaries is the formation of tubo-ovarian 
cysts with marked adhesions, which may give no symptoms until 
the child reaches the period of menstruation or later. 

Constitutional involvement may occur from any point, in 
the form of endocarditis, joint or periosteal involvements, and even 
meningitis. 

Treatment. — For the vulvitis I paint the areas thoroughly with 
a 10 per cent, silver solution, which, strange to say, causes relatively 
little pain. All the areas up to the hymen must be thoroughly 
painted and the sulci between the inner labia and the outer, the 
perineum, and the outer surface of the hymen must be thoroughly 
treated. The child should, once or twice a day, be seated for 
fifteen minutes in a very warm sitz-bath, for the purpose of remov- 
ing, as far as possible, the superficial desquamating layers. During 
the entire period, between treatments, and best applied immediately 
after the bath, a 2 per cent, protargol ointment, freshly made, 
is an ideal external medicament. 

For irrigating the vagina I use a thick rubber tube with a lumen 
one-third of an inch in diameter. Into this I insert a urethral 
rubber catheter, leaving one or two inches extending beyond the 
end of the rubber tube. The catheter is then inserted into the 
vagina for the purpose of irrigation. The thick rubber tube which 
covers the catheter is pressed closely against the hymen and the 
outer end of the vagina, prevents the outflow of fluid, and thor- 
oughly distends the vagina with the irrigating medium. On 
gradually releasing pressure by the outer tube, the fluid makes its 
exit without squirting into the face of the attendant. If, then, the 
speculum be introduced, and the fluid be removed by thin swabs, 
a clear picture of the local lesions can be obtained, and the treat- 
ment to be mentioned can be applied. 

So far as the vagina is concerned, these cases are treated by 
daily irrigations with bichlorid of mercury 1 : 5000, or by irriga- 
tion with boracic solution and the subsequent instillation with a 
curved eye-dropper of several tubes of 1 per cent, protargol. 
The treatment in the later stages consists of the injection of a 1 
per cent, silver solution. A very good ambulatory treatment 
consists of the irrigation, every day, with boracic solution, followed 
by the injection of protargol solution or by a protargol vaginal 
bath per speculum, and at later stages by the washing of the entire 



GONORRHEA IN CHILDREN 369 

vaginal canal with i per cent, silver with the aid of the speculum, 
and repeating this three times a week. In the very chronic cases a 
stronger solution of silver than i per cent, must be used through 
the speculum. The hymen of the child is very thin and very 
elastic, quite as elastic as the foreskin of the male. In the numerous 
instances in which I have used the curved eye-dropper or vaginal 
speculum, I have never found difficulty, even in the smallest chil- 
dren, in entering the vagina, nor have I ever torn any tissues or 
produced any bleeding. 

The external genitalia may be washed with bichlorid of mercury 
1 : 2000. The vagina is then irrigated with 2 quarts of a weak 
solution of permanganate of potash, followed by the injection of 
several pipetfuls of a 10 to 40 per cent, solution of argyrol. This 
is done twice a day. 

We may irrigate with 2 quarts of saturated boric acid solution 
and then inject several pipetfuls of a 1 per cent, solution of nitrate 
of silver. This is done twice a day until two weeks after the dis- 
charge ceases and no gonococci are found. Then continue the 
irrigation with boracic acid and use 2 to 5 per cent, silver nitrate. 

For the associated urethritis in children Sheffield uses the follow - 
ing urethral pencils introduced twice a day into the urethra : 

1$. Protargol gr. iij (to gr. xv) 

Iodoform gr. xv 

Bals. Peru gtt. vij 

Ext. bellad gr. j 

Ol. cacao q. s. 

F. crayons (2 inches long, T \ inch thick) no. xv. 



Urethral pencils may be made as follow 



1$. Ichthargan gr. y 1 ^ 

Ol. cacao 3iss 

F. urethral bacilli (2 inches long, |- inch wide) no. xii. 



For the treatment of rectal gonorrhea the rectum should be 
irrigated three times a day with any of the following solutions, 
after first cleansing with a normal saline enema: J to \ per cent, 
protargol; 4- per cent, albargin; 1 14000 argentamin; 1 15000 
permanganate of potash. 

With the aid of the small vaginal speculum the various silver 
salts may be directly applied to the rectum in stronger concentra- 
tion. Old stubborn cases demand the use of the Paquelin cautery 
applied to fissures and ulcerations. 
24 



370 MEDICAL GYNECOLOGY 

Improvement is evident: (i) by the character of the secretion,, 
which gradually becomes paler and thinner, and less in amount; 
(2) by the gradual disappearance of the red inflamed character of 
the acutest lesions and the resumption of normal color on the der- 
mal covering of the vulva; (3) by the healing of the vaginitis and 
the cervical erosions. The cure of a vulvitis of specific character 
would not be difficult. Generally we are dealing, however, with 
an invasion of the vagina and cervix, and absolute and complete 
rest in bed is essential to an early cure. A cure within six to twelve 
weeks may take place, with almost daily treatment. If the cervix is 
involved or if the vagina is deeply involved, recurrent virulent 
attacks may occur after symptomatic cure, though it is impossible 
to deny that in some cases a repetition of the original etiologic factor 
may have taken place. Ambulatory treatment is unsatisfactory. 
These should be hospital cases. 

Constitutional Treatment. — However, in the words of Bumm: 
1 ' All gonorrheas heal, if they do heal, finally through the natural 
reaction of the infected tissue. Without this help the complete 
elimination of the gonococcus is impossible. Most unpromising, 
therefore, are the chronic cases (in the cervix and uterus) in which 
the tissue is accustomed to the gonococcus and in which the mu- 
cosa epithelium, through long irritation, has undergone meta- 
plastic change to stratified squamous epithelium and only a slight 
secretion is found, consisting mainly of squamous epithelium. 
The cocci diminish or disappear under treatment, but on cessation 
of the latter reappear. Therefore constitutional treatment is 
often necessary." 

The typical characteristics of virulent gonorrhea are: (1) an 
acute beginning; (2) a chronic course; (3) resistance to treatment; 

(4) virulence in new areas or new media for a very long time; 

(5) probable extension in continuity; (6) possible constitutional 
involvement. 

The pathology of various lesions of acute gonorrhea shows the 
possibilities to be: (1) superficial involvement of the mucosa; 
(2) deep involvement extending into subepithelial connective 
tissues; (3) abscesses; (4) metastases; (5) constitutional involve- 
ment; and (6), which is very important, the early formation of 
adhesions. When these occur in the lower genital region, atresia 
or stenosis of the vagina or cervix may result. 



GONORRHEA IN ADULTS 
URETHRITIS 

Acute Gonorrheal Urethritis. — In acute gonorrheal urethritis 
the lining of the urethra is diffusely red and swollen. The ex- 
ternal meatus of the urethra is swollen and edematous. There is a 
purulent discharge. The urethra, when felt through the vagina, is 
thickened, infiltrated, and painful. There are a few exceptional 
conditions which simulate this involvement, such as septic ulcers, 
urethrocystitis after catheterization, puerperal fistulas, and de- 
generating malignant growths. The diagnosis of an acute gon- 
orrheal urethritis can be readily made by an examination of the 
secretion, which contains pus cells and intracellular and extra- 
cellular gonococci. A purulent discharge from an inflamed ure- 
thra, especially if the external meatus is red and ectropic, is almost 
surely gonorrheal. 

An acute urethral gonorrhea often causes very slight symptoms 
if limited to the anterior part of the urethra and heals better and 
much more quickly than in men. In three to four weeks the puru- 
lent secretion becomes milky and mucoid and contains many 
epithelia. Gonorrheal urethritis generally heals, and often without 
any treatment whatever. It is often healed in six to ten weeks 
and sometimes much earlier. 

Chronic Gonorrheal Urethritis. — In chronic urethritis there 
are red spots and streaks in the lining. There is redness about 
the follicles. The lining consists of stratified squamous epithelium 
plus leukocytes. The subepithelial tissue contains dilated vessels 
and an infiltration consisting mostly of mononuclear leukocytes. 
There is small- celled infiltration. This infiltration is especially 
marked near the external opening of the urethra, i.e., in the 
papillary excrescences or caruncles. 

In the chronic form there is a thick layer of squamous epithelium, 
but the subepithelial infiltrate is superficial. Gonococci are no 
longer present in the subepithelial tissue, but are present in the 

371 



372 MEDICAL GYNECOLOGY 

upper layers of the squamous epithelium or only in localized spots 
which look eroded. 

Involvement of the Follicles of the Urethra. — There are 
many follicles in the urethra. The glands of the urethra are like 
those of the prostate. Infection of these glands is a severe compli- 
cation, for it keeps up a chronic discharge of an infectious nature 
and may cause polyps. There may result a paraurethral abscess. 
In addition, there are the two glands of Skene, and the periure- 
thral glands, which are four or more and situated in the wall of 
the urethra about its external opening. They often have a trumpet- 
shaped outlet. These should be examined before or after examin- 
ing the urethra. Inflammation of the periurethral glands is acute 
or chronic. With recurrences, little abscesses may form. In- 
flammation of these periurethral glands constitutes the so-called 
urethritis externa — a very frequent condition. 

Caruncles. — Proliferation from or about Skene's glands occurs 
with continued irritation and causes caruncles, which are polypoid, 
hyperemic growths in the anterior third of the urethra, originating 
from the inferior wall. They are covered with mucosa and pro- 
trude from the urethra. They consist of a loose, vascular, inflam- 
matory infiltrate. 

Chronic urethral gonorrhea may last for years. In chronic cases 
the speculum (Fig. 39) shows erosions, infected lacunae, gray plaques 
surrounded by red areas, etc. The urethra feels hard and infiltrated 
and the secretion contains many degenerated epithelia. Infiltra- 
tion in the chronic cases may be diffuse or circumscribed. In the 
diffuse form the wall of the urethra is diffusely indurated. There 
are elevated folds of infiltration of a yellowish color. The healing 
areas are covered with epithelium and take on a grayish look. In 
the circumscribed form there are infiltrations about the lacunae and 
Littre's glands. The epithelium is easily injured in these areas. 
The infiltrations heal and form fine sclerotic bands, which finally 
take on a white color and may form minor strictures. 

Chronic gonorrheal urethritis may show spots of redness around 
the external meatus. Through the vagina the urethra feels thick- 
ened, infiltrated, and sensitive. A secretion is generally obtained 
readily on milking the urethra, but sometimes this secretion can 
only be gained if a period of from three to five hours elapses since 
the last urination. 



GONORRHEA IX ADULTS 373 

Mild Gonorrheal Urethritis. — Chronic cases often escape detec- 
tion, for a secretion can be obtained by massaging the urethra only 
in the morning before urination or if the patient has not urinated 
for several hours. Often the secretion is minimal in amount, yet 
symptoms may persist. A frequent form of mild gonorrhea con- 
sists of either a chronic or a subacute urethral infection, with or 
without an infection of the cervix uteri. There may be a sub- 
acute infection of the urethra without involvement of the cervix 
and vice versa. Gonorrhea is found more frequently in the cervix 
than in the urethra in older cases, whether chronic after an acute 
attack or subacute from the beginning. ( i ) A gonorrheal urethritis 
often heals as quickly or quicker than in men. The prognosis 
of even an acute gonorrhea is good if it is located in the urethra, 
either with or without treatment. (2) The largest number of 
gonorrheal infections are non-acute. Infection is transmitted to 
women from male urethras and prostates which are supposedly 
healed or which give forth an unrecognized inflammatory secretion 
or which give forth a discharge which is considered innocuous. In 
such cases pus does not come in contact with the urethra during 
the act of copulation. The infecting elements are expelled with 
the seminal fluid and thus come in contact with the cervix alone. 
When such secretions do infect the urethra, the character of the 
infection is very mild. 

Symptoms. — The symptoms of urethritis depend for their 
severity on the acuteness of the involvement, but more particularly 
on the location. If the anterior part of the urethra is affected, 
the patients experience only a slight burning or an itching, due to 
irritation of the external meatus and the vestibule. Involvement 
of the posterior half of the urethra in the form of a urethrocystitis 
may give symptoms of such severity as to simulate a cystitis. 
Among the symptoms of the latter form are frequency of urination, 
painful and uncomfortable desire for urination; micturition may 
be so frequent and painful as to deserve the name tenesmus. In 
some cases there may be ischuria, that is, a difficulty or impossi- 
bility of voiding urine or of emptying the bladder. The bladder 
has to be emptied several times daily with the catheter. In such 
cases attempts at urination may cause a flow of blood. In chronic 
cases there may be simply a frequency of urination, noticeable at 



374 MEDICAL GYNECOLOGY 

night as well as by day. The desire for urination occurs when 
there is very little urine in the bladder. In other instances the 
desire for urination at night is not so marked, but during the day, 
when the patient is in the erect position and the urine in the bladder 
touches the urethrocystic sphincter, frequency of urination is 
pronounced. In the milder chronic cases, especially in such as 
have a minimal amount of secretion, there is simply a tickling or 
burning on urination or a sensation of itching and a feeling of dis- 
comfort after voiding urine. 

Diagnosis. — In acute cases the very existence of a purulent 
discharge from an inflamed, sensitive urethra, especially if the 
external meatus is red and ectropic, is almost absolute proof of 
gonorrhea. Examination of the secretion by microscope shows 
gonococci. In the acute cases of urethritis, or especially of urethro- 
cystitis, the amount of pus in the remaining urine, after the first 
few drams are passed voluntarily, is small. In a cystitis, however, 
all the urine is cloudy and contains pus cells, epithelia, and blood, 
especially in the last few drams, whether passed voluntarily or 
withdrawn by the catheter. 

In chronic cases a milky, thick, mucoid secretion can be obtained 
by massaging the urethra through the vagina. Pus cells and gono- 
cocci may be obtained by scraping the urethra with a dull spatula, 
but many such secretions, when examined, are found to contain 
numerous squamous epithelia of all sizes and varying numbers of 
pus cells. Gonococci are often absent or found with difficulty. 
Chronic gonorrheal urethritis may show spots of redness about 
the external meatus. Through the vagina the urethra feels thick- 
ened, infiltrated, and sensitive. A secretion is generally obtained 
readily on milking the urethra. In very old cases or in cases 
subacute from the beginning, whether the amount of discharge 
obtained is large or minimal, the microscope shows mainly squa- 
mous epithelium, very few pus cells, and absolutely no gonococci. 
The fewer the pus cells, the greater is the probability of the absence 
of surface erosions and the greater is the probability of involvement 
of the glands. 

In diagnosing chronic or subacute urethritis the urethra should be 
massaged through the vagina from the internal toward the external 
meatus (Fig. 22). By massaging first the anterior half of the 



GONORRHEA IN ADULTS 375 

urethra and then the posterior, we may know by the discharge ob- 
tained by each of these manipulations whether the anterior half or 
the posterior half or the whole urethra is involved. To determine 
whether involvement of the urethral glands is the cause of the 
chronic discharge the patient should void urine, or else the bladder 
should be injected with a solution directly through the urethra 
without the aid of a catheter. The latter procedure (after gentle 
massage of the urethra has been done) clears the surface secretion 
away. If, after so doing, the urethra is again massaged and more 
secretion is obtained, it comes in all probability from beneath the 
surface, that is, from the glands of the urethra. Such cases may 
show nothing but squamous epithelia under the microscope and 
gonococci are often not found. 

In cases of chronic urethritis a sound introduced into the urethra 
shows the canal to be sensitive. Pain is caused by the sound 
and irregularities may be felt which, too, are very sensitive. The 
use of the sound aids in differentiating involvement of the urethra 
from an involvement of the bladder. 

Treatment. — In the treatment of acute gonorrheal urethritis 
attention is to be paid to the diet, which should be mainly fluid. 
All irritating foods should be avoided. Alcohol in any form should 
be absolutely prohibited. Rest in bed hastens recovery to a con- 
siderable extent. Acute gonorrheal urethritis is to be treated by 
internal medication only. Urotropin is to be taken, 7 grains three 
to five times a day; salol, 5 grains, should be added. With this 
medication plenty of water should be taken, a glass of water being 
administered with each dose of these drugs. Helmitol, 15 grains, 
is sometimes better than urotropin. 

Local treatment of the urethritis is to be begun only in the sub- 
acute stage. At this time balsam of copaiba, 15 grains in capsules, 
or oleum santali may be administered three times a day. Of the 
internal antigonorrheic remedies, arhovin is said to be free from 
the untoward effects of the balsams. Arhovin internally is indicated 
in inflammation of the urethra associated with pain on urination 
and cystitis. In the chronic form it is sometimes of great relief. 

Arhovin is an aromatic fluid given internally in capsules. It 
causes acidity in alkaline urine, even in one undergoing ammoniacal 
fermentation. It is a sedative and anesthetic to mucosae and does 



376 MEDICAL GYNECOLOGY 

not annoy the stomach. Six to twelve capsules, each containing 
4 grains, are to be taken daily. 

Gonosan is an oleaginous substance soluble in ether, alcohol, or 
chloroform. It is the active principle of kava-kava dissolved in 
sandal- wood oil. Gonosan contains 20 per cent, of kava and 
80 per cent, of sandal- wood oil. Kava renders mucous membranes 
ischemic and anesthetic. The dose is one or two capsules four 
times a day after meals. It lessens secretion, checks the growth 
of gonococci, is a diuretic, and prevents pain. 

Of the drugs to be used for the local treatment of the urethra I 
find that nitrate of silver and protargol are the two most valuable. 
In the earlier periods protargol, 1 per cent, or stronger, can be 
injected into the urethra with a pipet without much annoyance 
to the bladder, or else several ounces are injected by syringe 
directly into the bladder per urethram with the Frank syringe, 
and are then voided (Fig. 30). The patient should first urinate 
and then the urethra should be massaged to clear the ducts and 
crypts of secretion before treatment is begun. 

When small amounts of the stronger solutions are to be injected, 
the eye-dropper pipet is sufficient, the bladder being protected by 
a preliminary filling with any mild solution (Figs. 28, 31). 

Before applying silver nitrate it is better to first have the patient 
urinate and then to massage the urethra. Then inject into the 
bladder several ounces of J to \ per cent, solution of protargol. 
After removing the catheter inject into the urethra with a large 
straight glass pipet with large rubber bulb, several tubefuls of 1 
per cent, silver nitrate, moving the pipet so that half the quantity 
passes into the bladder while the other half will run out of the 
urethra. The protargol solution in the bladder should be then 
voided at the end of three to five minutes. In the later stages, if 
this method fails, 1 per cent, ichthargan or 5 per cent, nitrate of 
silver may be injected into the urethra every other day, the bladder 
being protected by a solution injected into it. This treatment 
of the urethra should be carried out three times a week. 

Applications may be made to the urethral mucous membrane 
by the aid of cotton wrapped about thin wooden or metal applica- 
tors; or it may be accomplished by the aid of cotton wrapped 
about the tip of a Braun syringe, the fluid being injected to moisten 



GONORRHEA IN ADULTS 377 

the cotton after introduction into the urethra (Figs. 51, 52). 
By gently withdrawing the tip of the syringe the cotton may be 
left in place for any desired time. By any of these methods we 
may apply stronger solutions. 

Protargol works well when in contact with a mucous membrane 
for several minutes, and is therefore of value in cystitis, while the 
silver nitrate solutions act quickly and therefore work better in 
the urethra. If, however, protargol is desired, it may be applied 
with the aid of cotton wrapped on applicators or on the Braun 
syringe and left in place five to ten minutes. 

With the Frank syringe the urethra may be irrigated directly into 
the bladder without the aid of a catheter. Various solutions may be 
used, such as 1 per cent, ichthyol, 1 to 5 per cent, protargol, J 
per cent, albargin, 5 per cent, argyrol, etc. 

The same procedure may be carried out in milder cases or as a 
preliminary to local applications by using a solution composed of 
1 dram of a combination of zinc sulphate, boric acid, and alum 
to the pint of water. 

In the treatment of urethritis the order as given below is followed. 
One may begin with protargol or largin of a strength of 1 to 2 
per cent.; subsequently argentamin, ichthargan, or nitrate of 
silver is used in a solution of 1 : 1000 up. Finally, the simple astrin- 
gents are applied, if necessary. 

In chronic cases it may be necessary to introduce into the urethra 
sticks of cacao-butter containing protargol; or sticks containing 
iodoform or ichthyol may also be used. A method which is some- 
times of value in the chronic form when the follicles are infected 
and when erosions are present is the injection into the urethra 
with a pipet of boroglycerin every other day. If this treatment is 
applied for six to twelve days, the subsequent application of silver 
sometimes cures a previously resisting case. In the still more 
stubborn cases due to stricture, to erosions, to involved follicles, 
20 to 50 per cent, silver must be applied locally with the aid of the 
small speculum (Fig. 39) or else the actual cautery must be used. 

It is sometimes necessary to dilate the urethra if it is infiltrated. 
Stricture of the urethra does not occur until the chronic stage, and 
it may be treated by gradual repeated dilatations, preferably with 
the Hegar dilators. The urethra is then painted with tincture 



378 MEDICAL GYNECOLOGY 

of iodin or 5 to 20 per cent, cupric sulphate or 5 to 20 per cent, 
silver with the aid of applicators. In continued involvement of 
the glands of Skene it is necessary to slit them up for their entire 
length and to cauterize them (see page 51). 

In the treatment of urethritis drugs are used in the following 
order: (1) Such as are purely antiseptic and not astringent; 
(2) antiseptic astringents; (3) astringents. 

An ideal silver salt should (1) not coagulate albumin, (2) should 
not precipitate sodium chlorid, (3) be soluble in water, (4) cause no 
pain, (5) cause no irritation. These purposes are fulfilled by the 
newer silver preparations. 

Among the antiseptic but not astringent silver salts used in ure- 
thritis are the following: protargol (8 per cent, silver), used in 
the strength of J to 5 per cent.; largin (11 per cent, silver), J to 
2 per cent., a stronger antiseptic than protargol; argonin (6 per 
cent, silver), used in \ to 5 per cent, solution; albargin (15 per 
cent, silver), used in the strength of 1 : 1000 to 1 : 100; argyrol, 
2 to 20 per cent, solution. 

Among the antiseptic astringents which are ordinarily used to 
diminish hyperemia and hypersecretion in urethritis, which are 
germicidal but which cause slight irritation, are: nitrate of 
silver, 1 : 1000 to 1 : 100; argentamin, 1 : 1000 to 1 : 100; 
ichthargan (30 per cent, silver combined with ichthyol), 1 : 1000 
to 1 : 500, is said to penetrate deeper than silver nitrate; ichthyol, 
1 : 500 to 1 : 100. 

Among the astringents which are used to diminish hyperemia and 
hypersecretion are: zinc sulphate, 1 : 500 to 1 : 100; acetate of 
lead, 1 : 100 to 1 : 50. 

Urethral suppositories, called bougies, pencils, or bacilli, consist 
of a base of glycerin, gelatin, or cacao-butter. 

The glycerin suppositories consist of a base of 95 per cent, 
glycerin and 5 per cent, stearic acid. The gelatin ones are made 
of boroglycerid and gelatin. These two latter forms require a 
special machine for their manufacture, and are made containing 
various drugs by large drug firms. Any druggist can make the 
suppositories with the base of cacao-butter. Although glycerin is 
of value, the cacao-butter base suffices in most instances. A 
suppository for the urethra 2 inches long and \ of an inch in 



GONORRHEA IN ADULTS 379 

diameter contains about 8 grains of cacao-butter; one 2 J inches 
long and J of an inch thick contains about 20 grains of cacao- 
butter. On this basis they may be made to contain various 
percentages of the various drugs. To obtain a suppository con- 
taining 1 per cent, of the desired medicament in a suppository 2 
inches long and J of an inch in diameter: 

1$. Iodoform gr, 

Or— 
Protargol gr 

Or— 
Arg. nitr gr 

Or— 
Ichthargan gr 

Or— 

Zinci sulph gr. 

Butyr. cacao gr. viij 

F. tal. suppositoria urethral. (2$ inches long, | inch thick) no. x. 

To order a suppository 2\ inches long and \ of an inch thick 
which contains 1 per cent, of the following drugs: 

1$. Iodoform gr, 

Or— 
Protargol gr 

Or— 
Arg. nitr gr 

Or— 
Ichthargan gr. 

Or— 

Zinci sulph gr 

Butyr. cacao gr 

F. tal. suppositoria (2 \ inches long, \ inch thick) no. x. 



1 

3" 
XX 



Increasing the percentage of the drug in any of these supposi- 
tories is rendered easy by simply making any desired multiple of 
the amount noted in the above forms. 

The following represents Finger's treatment of gonorrheal ure- 
thritis: For gonorrheal urethritis use injections of 1 per cent, 
protargol sent directly through the urethra into the bladder. In 
the later stages the same thing may be done with 1 : 1000 argentamin 
or silver nitrate. By some, acute urethritis is treated by irrigations 
of the urethra with 4 per cent, gallobromol in large amounts. 
Gallobromol is a combination of gallic acid with bromin. For 
subacute and chronic urethritis the urethra is painted with 20 per 
cent, gallobromol solution, or 50 per cent, gallobromol sticks are 
introduced into the urethra. In acute cases gonosan and oleum 



380 MEDICAL GYNECOLOGY 

santali are given, and if the bladder is involved, sodium salicylate 
and salol are used. 

In subacute cases the urethra may be treated by the introduction 
of iodoform sticks, or be painted with tincture of iodin or 2 to 5 
per cent, silver nitrate with the aid of a short endoscope. 

If there is marked infiltration of the external opening of the 
urethra or of the entire urethra, gradual dilatation with metal 
sounds should be practised, followed immediately by irrigations 
or painting of the urethra. 

Folliculitis about the external opening of the urethra is cured 
only by destruction of the follicles with the silver stick or with the 
cautery. 

GONORRHEAL CYSTITIS 

Frequent as is the occurrence of a gonorrheal urethritis in the 
female, extension of the inflammation to the bladder was referred, 
for a long time, to a complicating cystitis produced by other bac- 
teria or to involvement by the gonococci of the neck of the bladder 
alone. In recent years many instances of purely gonorrheal 
cystitis have been definitely diagnosed, so that its entity is positive. 

Histopathology. — In the early days Barlow was one of the first 
to find, in two cases of cystitis, only gonococci in the urine. The 
cystoscope showed diffuse inflammation of the entire bladder 
mucosa. Krogius, in two cases of purulent cystitis, found numer- 
ous gonococci in the epithelial cells in the urine. Wertheim, 
Bierhoff, and others have verified this condition many times. 
It is a fact, however, that gonorrheal cystitis is not so frequent, 
and most of the cases which have the subjective symptoms of gonor- 
rheal involvement of the bladder are really cases of posterior ure- 
thritis or urethrocystitis. 

How deeply the bladder mucosa may be involved, however, 
is shown by a study of a case of purulent cystitis in a nine-year- 
old child, in which Wertheim found only gonococci. In narcosis 
a piece of the bladder mucosa was removed with the aid of the 
cystoscope. Gonococci were obtained in the cultures from the 
excised specimen. The microscopic examination of the specimen 
showed: (1) Gonococci between the epithelial cells; (2) gonococci 
extending in rows into the subepithelial connective tissue and 



GONORRHEA IN ADULTS 381 

lying almost entirely extracellular; (3) the surface of the mucosa 
covered with fibrin layers; (4) gonococci in the blood-vessels. 
The gonococci were not always of typical form, but were rather 
involution forms and groups looking like masses of granules. 

Symptoms. — The symptoms are those of a very acute cystitis. 
The urine of a gonorrheal cystitis is purulent and contains pus, 
epithelia, and sometimes red blood-cells or blood. In the acute 
cases the last few drops obtained on emptying the bladder by 
catheter contain very much pus, epithelia, and blood. The urine 
has no odor of ammoniacal degeneration. The standing urine 
forms a sediment of pus, and examination by the microscope shows 
gonococci. In the chronic cases pus is obtained by the centrifuge 
and can be detected by the microscope. The first urine passed, 
which washes out the urethra, should be excluded. In some cases 
the urine is so slightly purulent that the cystoscope is essential 
to the making of a diagnosis of involvement of the bladder. 

Treatment. — Acute gonorrheal cystitis should be treated by 
the internal administration of salicylate of soda or salol, 5 grains 
every three hours. The use of salol results in the liberation of 
carbolic acid and salicylic acid in the urine. Urotropin is a very 
valuable urinary antiseptic as an adjunct to salol in doses of 7 
grains every three hours. It is of great importance in the chronic 
form. Helmitol, 7 to 10 grains three times a day, gives off more 
formaldehyd in the urine than does urotropin. Saliformin, 5 
grains every four hours, is a valuable urinary antiseptic. A 
valuable combination consists of sodium salicylate, 1 dram; 
urotropin, ij drams; tincture of hyoscyamus, 4 drams; elixir 
simplex, q. s. ad 4 ounces; 1 dram of this mixture being given in 
water several times a day. Benzoic acid, 10 grains three times a 
day in capsules, is a local alterative and antiseptic. It acts well 
in gonorrhea, and expecially well in ammoniacal cystitis. Methyl- 
blue, 5 grains several times a day in capsules, is only mildly anti- 
septic and is of aid in the non-gonorrheal forms. 

1$. Urotropin gr. vij 

D. tal. tabel. no. xv. 

S. — One t. i. d. with water. 

1$. Sodii salicylatis 3iij 

Div. in dos. no. xii. 

S. — One powder t. i. d. with water. 



382 MEDICAL GYNECOLOGY 

1$. Ext. hyoscyam gr. ss 

Salol gr. v 

Urotropin gr. v 

F. tal. caps. no. xx. 

S. — One every three hours with water. 

The pain associated with cystitis in the acute stage may be re- 
lieved by a suppository containing 1 grain of extract of opium, 
1 grain of extract of hyoscyamus in oil of theobroma. If this does 
not relieve the pain and spasm, morphin must be given by the 
needle. The fluidextract of uva ursi, 1 dram three times a day, 
is a slight stimulant and astringent and is of value in the early 
stages. The fluidextract of kava-kava, 3ss three times a day, 
is highly comforting, especially in gonorrheal cystitis. Balsam of 
copaiba, 15 grains in capsules, is a local stimulant to the mucous 
membrane. Among the other drugs taken internally are the 
alkalies, which should be given only if the urine is very acid. 
They are of value in acid cystitis which is not gonorrheal and in 
cases of irritable bladder associated with acid urine. 

1$. Ext. opii gr. j 

Ext. hyoscyam gr. j 

Ol. theobrom., q. s. 

F. tal. supposit. rectal, no. v. 

S. — One when necessary. 

1$. Infus. fol. uvae ursi § xv 

Syr. papaveris 3iv 

S. — One tablespoon every two hours. 

The local treatment of acute cystitis is carried out by irrigation. 
A preliminary washing of the bladder is of value to remove pus 
and bacteria. Normal salt solution, 2 drams to the quart, or mild 
boracic solution, 1 per cent., is used for the preliminary washing, 
either of which fluids have a non-irritating influence on the mucous 
membrane. 

The preliminary irrigation should be followed by irrigation with 
fluids which have a destructive action on the bacteria and which 
exert a stimulative influence on the epithelium and so aid in the 
throwing off of bacteria. Protargol, while not quite so valuable 
in this respect as silver, is much less irritating and should be used 
in the acute stages. Protargol works well even in weak solutions 
of 1 : 800 up to 1 : 500 in the acute stages, and from 1 to 5 per cent, 
in the more stubborn cases. Several ounces are to be injected 



GONORRHEA IN ADULTS 383 

into the bladder and allowed to remain for five to ten minutes. 
If the bladder is extremely sensitive, it should be first anesthetized 
by injecting into the bladder an ounce of a 1 per cent, solution of 
eucain or of a 4 per cent, solution of antipyrin. In place of pro- 
targol, the bladder may be irrigated by J to J per cent, watery 
solution of ichthyol, which should be left in place for several 
minutes (Fig. 31). 

In the subacute stage or in stubborn cases nitrate of silver dimin- 
ishes congestion and stimulates regeneration, and is, in addition, a 
very valuable germicide. When used in solution of 1 : 10,000 and 
gradually increased to 1 : 500, and in very stubborn cases even to 
1 : 100, it renders the urine clear. If too annoying, it should be 
preceded by the use of an anesthetizing solution. The strength 
of any of the irrigations depends upon the sensitiveness of the 
bladder, which can be judged by the preliminary washing with 
saline or boracic solution and by the amount which the bladder 
can hold when this preliminary solution is injected. 

Milder forms of cystitis may be treated by irrigations with J 
per cent, salicylic solution or by 2 per cent, resorcin solution, which 
are mildly germicidal. Permanganate of potash is an antiseptic 
of value and may be used in the strength of 1 : 10,000 to 1 : 2000. 

In chronic cystitis nitrate of silver 1 : 3000 or 1 : 500 should be 
used every other day. The stronger solutions must be preceded 
by the anesthetizing instillation. 

Finger's method is as follows: In the acute cases of urethro- 
cystitis and cystitis Finger advises a symptomatic and expectant 
treatment. Regulation of a hygienic, dietetic character is often 
enough to cause a rapid cure of the condition. Of prime impor- 
tance is rest in bed. As fluids he prescribes thick decoctions; 
among them is: Decoctio fol. uvas ursi, 500; syr. papaveris, 15; 
one tablespoon every two hours. 

If there is hematuria, he administers styptics, among which he 
includes solutio ferri sesquichlorati. 

I}. Liq. ferri sesquichl gtt. xv 

Syrup, aurant. cort o vj 

Aq. destillat o vj 

S. — One tablespoon even' hour. 

In stubborn cases of hematuria he injects 2 to 3 c.c. of a 1 : 1000 
adrenalin solution into the bladder with very good results. 



3^4 MEDICAL GYNECOLOGY 

Pain is treated by extract of belladonna and morphin in supposi- 
tories or by subcutaneous injections of morphin. He also advises 
warm moist applications to the abdomen. 

When the irritating symptoms have disappeared and the objec- 
tive symptoms still remain, he makes use of internal treatment 
and of irrigation. Internally he used oleum santali, gonosan, 
balsam of copaiba, which rapidly clear the urine. If these do not 
produce good results, he makes use of a combination of extract of 
cannabis indica and extract of hyoscyamus, or of benzoic acid, or 
sodium salicylate or salicylic acid, and also urotropin. 

1$. Acidi benzoici 5 j 

Syrup, cort. aurant 5 v 

Aq. destillat § viij 

S. — One tablespoon every two hours. 

1$. Caps, gonosan no. xx. 
S. — One t. i. d.; or 
S. — Two t. i. d. 

1$. Ol. santali gtt. x 

Disp. tal. dos. no. xx. 
S. — One capsule t. i. d. 

1$. Ext. cannab. ind gr. iij 

Ext. hyoscyam gr. v 

Sacch. lactis 5 iss 

M. f. pulv. Div. in dos. xij. 

S. — Three to five powders daily. 

Care is necessary in the use of alkaline waters. In the mucous 
catarrhal form with acid urine, he uses with good effect the waters 
of Giesshuebl and Wildungen. 

If the urine is only slightly acid, or alkaline, and if there is a 
tendency to phosphaturia, these waters are contraindicated, since 
they increase the alkalinity of the urine, increase the phosphaturia, 
whereas it should be our duty to keep the urine acid, to make it 
acid if alkaline, for which purpose the balsams, sodium salicylate, 
benzoic acid, and especially salicylic acid are best. 

If the urine still remains cloudy and if it contains mucus and pus, 
local therapy is indicated. The bladder is irrigated by injecting 
8o to ioo c.c. of sterile water into it and letting the fluid run out 
through the rubber catheter. This is repeated two or three times. 
Then various solutions may be injected into the bladder and left 
in place for three to five minutes or longer. The watery solutions 



GONORRHEA IN ADULTS 385 

to use are salicylic acid \ per cent., resorcin 3 to 5 per cent., 
protargol \ to 1 per cent., permanganate of potash 1 : 2000, 
boracic acid 3 : 200, nitrate of silver 1 : 1000 to 1 : 500, largin \ 
to 1 per cent. 

In chronic cystitis, in addition to local and internal treatment, 
a cure is often obtained only through a general tonic regime. 



GONORRHEAL VULVITIS 

Diffuse structural involvement of the vulva of adults by the gono- 
coccus is rare. The vulva is often irritated by the gonorrheal dis- 
charge coming from the higher areas of the genital tract or from the 
urethra. The vulva is red and is eroded in spots which are covered 
with pus. The small labia and clitoris may be edematous. The 
labia are swollen, red, eroded, and covered with pus and crusts. 
The vestibule is red and swollen and shows very red spots. The 
ring of the hymen is swollen and red and pus is collected in all the 
recesses and in the fossa navicularis. The openings of the ducts 
of Bartholin are red. In all the folds we find eroded spots and 
membranes. 

Acute gonorrheal vulvitis in adults is rare. The symptoms are 
burning, itching, and pain. The flow of urine increases the annoy- 
ance. There is much secretion. There is heat and burning in 
the vulva. Walking is painful through rubbing together of the 
affected parts. The inguinal glands are swollen and sensitive. 
The parts are sensitive to touch and examination. This condition 
improves readily, and in ten days to two weeks the eroded areas 
are cleared up and evidences of inflammation are almost gone. 
Acute vulvitis is of various degrees of virulence and the above 
annoyances may be relatively slight. 

There are numerous small glands in the vulva situated about the 
urethra, in front of the hymen, and in the fossa navicularis, which, 
when infected, may form small purulent nodules. Small abscesses 
may result. They may be of the appearance of small furuncles, 
really forming a gonorrheal furunculosis. In the acute cases we 
see red spots from which a purulent or mucoid secretion may be 
pressed out. 

In a chronic vulvitis the glands in the vestibule, the glands of 
2 5 



386 MEDICAL GYNECOLOGY 

Bartholin, and the glands about the external opening of the urethra 
are involved and secrete pus or mucopus. The fourchet is eroded. 
Gonorrheal vulvitis in adults is secondary to gonorrhea of the cer- 
vix and uterus. Vulvitis without purulent urethritis and without 
purulent cervical or uterine discharge is probably not gonorrheal. 
In chronic vulvitis we must exclude vulvitis due to masturbation, 
vulvitis due to uncleanliness and to other bacteria, as well as 
vulvar changes due to syphilis, etc. 

Treatment of Chronic Vulvitis.— Acute gonorrheal vulvitis 
should be treated by cleansing of the external structures. Mild 
solutions of corrosive sublimate, 1 : 5000 to 1 : 10,000, should be 
used. The parts should be carefully separated and gently sponged 
with cotton soaked in this solution. Bichlorid gauze should then 
be placed in such a manner that the two sides of the vulva are kept 
apart. A moderately tight T binder should be applied. The vulva 
should be washed in this manner several times daily, each washing 
being preceded by a vaginal douche of bichlorid of mercury, 1 : 2000. 
The patient should be kept in bed, laxatives should be administered, 
and urotopin and salol, 5 grains of each, should be administered 
four times a day. If the skin is sensitive and red and is irritated 
by the action of the bichlorid of mercury, the gauze dressing should 
be saturated with a solution of acetate of aluminum. In the sub- 
acute stage the vulva is to be treated by the silver salts. It should 
be painted with argyrol 25 per cent., or with nitrate of silver 10 
per cent., and the surfaces should be kept dry by gauze dusted 
with dermatol and nosophen. 

The successful treatment of chronic vulvitis is sometimes diffi- 
cult. Infiltrated, swollen, and suppurating follicles must be 
painted with silver solution, 10 to 20 per cent. The best treatment 
is to destroy the follicles or plaques with the actual cautery. 



BARTHOLINITIS 

Infection of either of the two vulvovaginal glands of Bartholin 
by the gonococci may occur as early as fourteen days after the 
primary infection, but it generally occurs weeks or months or even 
years afterward. It is especially frequent among puellae publicae. 
The duct of the gland is red and swollen. The gland itself may be 



GONORRHEA IX ADULTS 387 

scarcely felt. Pressure on the posterior part of the large labium 
forces pus out of the gland. The patient is sensitive to pressure 
and there is some pain on walking or sitting. Closure of the duct 
causes a spindle-shaped or round swelling the size of a hazelnut. 
If the retained purulent secretion is much in amount, we get a 
pseudo-abscess the size of a pigeon's egg or larger. 

Abscess of the Gland. — In the acute form, which is practically 
always due to gonorrhea, there is an acute swelling of the whole 
gland. Secretion finds no outlet through the swollen duct and 
purulent contents are accumulated. The surrounding tissue be- 
comes infiltrated and there is seen in the lower third of the large 
labium a swelling the size of a small egg, which projects toward 
the introitus and pushes the other labium to the other side. Its 
surface is red and swollen. The whole area is markedly sensitive; 
there is pain and a sensation of burning and irritation. If the 
surface at any part becomes thinned out, the abscess may break 
spontaneously on the outer surface of the labium, or more rarely 
may break into the rectum. 

An acute non-gonorrheal infection of the Bartholinian glands is 
rare. The purulent gonorrheal form is considered to be a mixed 
infection and results as follows: The duct is inflamed and in it 
there is a subepithelial infiltrate. The lumen is filled with cell 
detritus, with squamous epithelia, and gonococci. The duct is 
easily obstructed, pus accumulates, and a pseudo-abscess results. 
If a mixed infection takes place when the gland becomes affected, 
there are found, in addition to gonococci, staphylococci and strep- 
tococci. If the pus is fetid, it is due to anaerobic bacteria. 

In chronic cases the outlet of the duct is red, flea-bite in appear- 
ance, forming the so-called maculae gonorrhceicse. There is a 
secretion of mucopurulent or mucoid character. 

Chronic Bartholinitis. — A chronic Bartholinitis often repre- 
sents the only spot on the external genitalia which is affected in 
chronic gonorrhea. If there is an accumulation of secretion, a 
nodule is present. If not, there are only red flea-bite spots about 
the openings of the ducts. 

Subacute Bartholinitis. — In subacute involvement there is 
only slight redness and swelling and no pus accumulation is retained 
in the gland. The duct is involved by a catarrhal inflammation. 



388 MEDICAL GYNECOLOGY 

Here also the opening of the duct is red, forming the so-called 
maculae gonorrhoeae. If the outlet through the duct is obstructed, 
a cyst may be formed. In chronic cases the gradual accumulation 
of secretion (in which cocci are absent) and without inflammatory 
symptoms may form a cyst of the gland. 

Cyst of the Gland of Bartholin. — Cyst of the gland of Bartho- 
lin is not necessarily gonorrheal, according to general opinion. 
However, the view of Veit and others, with which I agree, is that a 
gonorrheal infection, perhaps dating back to the years of child- 
hood, has produced a cyst in the clear secretion of which inflamma- 
tory evidences are entirely gone. 

Treatment. — In the early stages of a Bartholinitis rest and cold 
applications are indicated. As soon as an abscess forms it must 
be treated by incision, irrigation with corrosive sublimate, and 
packing with iodoform gauze (see page 52). In the chronic cases 
excision must be practised. 

In chronic Bartholinitis the glands must be treated by irriga- 
tions and injections if the duct is large enough. If the duct 
is not large enough, a hypodermic injection must be made into 
the glands directly and a few drops of a 1 to 2 per cent, silver 
solution should be introduced. In this way the involved gland 
or cyst may be brought by an active reaction to obliteration. The 
best treatment is to remove the gland or cyst surgically. 



GONORRHEA OF THE ANUS AND RECTUM 

Baer found that in one hundred and ninety-one cases of gonor- 
rhea there was rectal involvement in 30 per cent. It is due to the 
outflow of secretion. There is a sensation of heat and burning 
in the anus which is increased on defecation. Erosions, ulcers, and 
especially fissures of the anus are present and sometimes blood is 
passed. A secretion is generally obtained after manipulation or on 
the use of the rectal speculum, and shows gonococci. On examina- 
tion with a speculum the rectal mucosa looks red and edematous 
and may show ulcerations, as a result of which infiltrations take 
place. This condition is frequently overlooked. Many women 
suffering from fissures of the anus and from inflamed " hemor- 
rhoids" are really suffering from gonorrheal involvement of the 



GONORRHEA IN ADULTS 389 

anus and rectum. I have found this to be the case in many 
instances where no other symptoms were complained of. Further 
examination shows an unrecognized cervico-uterine gonorrhea. 

Treat ment. — For the treatment of rectal gonorrhea the rectum 
should be irrigated three times a day with any of the following 
solutions, after first cleansing with a normal saline enema : 1 to 5 
per cent, protargol; ^ per cent, albargin; 1 : 4000 argentamin; 
1 : 5000 potash hypermanganate. 

With the aid of a rectal speculum the various silver salts may be 
directly applied in stronger concentration. Old stubborn cases 
demand the use of the Paquelin applied to fissures and ulcerations. 



GONORRHEAL VAGINITIS 

In chronic gonorrhea in the female the vagina may seem normal, 
but in acute cases we may have an involvement of the vagina 
which is secondary and is due to the continued discharge of gono- 
coccus-bearing secretion from the cervix and uterus. The vagina 
is then red and swollen and there is a purulent secretion, especially 
in younger persons. 

Histopathology. — In children the cocci readily enter the vaginal 
epithelium. When the gonococci enter the vaginal mucosa the 
changes are : (1) The surface epithelium is gone; (2) all the epithe- 
lium is gone in spots; (3) gonococci enter into the epithelium in 
certain areas in bands; (4) the gonococci may enter very deeply 
into the tissue in spots and may extend beyond the epithelial limit. 
Though the gonococci are generally in the superficial connective 
tissue, yet in certain areas they may become deeply embedded. 

Ghon and Schlagenhaufer have found that the subepithelial 
connective tissue shows small-celled infiltration. Papillae with 
dilated vessels project above the surface and the epithelium of 
these papillae is only of one or two layers. There are many 
polynuclear leukocytes in the infiltrate. In the posterior fornix 
the epithelium is loosened and infiltrated with polynuclear leuko- 
cytes. Papillae infiltrated and rich in vessels project like small 
polyps and their epithelial covering is of one layer or is gone. The 
change is most intense in the region of the external os. Here 
the epithelium is gone and numerous papillae project above the 



39° MEDICAL GYNECOLOGY 

surface. Mononuclear and polynuclear leukocytes cover the 
surface. 

Symptoms. — When the vagina is affected by gonorrhea, it is 
very red and bleeds easily. There are many eroded areas cov- 
ered by a membrane composed of fibrin, pus cells, epithelium, 
and gonococci. There is especially much membrane in the 
posterior fornix. The vagina is very sensitive on examina- 
tion, there is a sensation of heat and burning in the vulva, the 
patient can scarcely walk. Pressure on the abdomen causes pain, 
and coughing, or even talking may be painful. There is elevation 
of temperature. There is a feeling of weight and burning in the 
genitalia. There is purulent discharge. Pain extends into the 
pelvis and is increased by defecation and activity. There is slight 
fever. Vulvitis and intertrigo and eczema are added. The introi- 
tus vaginae is swollen and red and eroded spots are noted. Some- 
times the vagina is so sensitive that even most careful examination 
causes vaginismus. 

After the acute stage is over, in some cases the vaginal folds are 
infiltrated and covered with small red granules, the so-called 
vaginitis granulans. The acute stage lasts eight to ten days. 
Gonorrheal vaginitis is generally healed in three or four weeks. 
Recrudescences occur, especially after menstruation. 

Bumm says it heals in three to four weeks. The pus cells 
become fewer, more epithelia appear, and the discharge becomes 
white and granular. Light recrudescences may occur at menstrua- 
tion. Bumm denies the existence of chronic vaginal gonorrhea. 
He says that vaginitis granulosa, which is generally considered a 
form of chronic gonorrhea, is not due to this etiology. He says 
that cocci cannot be found in most of these cases and that when 
the secretion is inoculated on sensitive mucous membranes, nega- 
tive results are obtained. 

Gonococci are hard to find in the vaginal secretion because of 
the other cocci present. Irrigation of the vagina with silver solution 
causes cell desquamation. If then the vagina is scraped with a 
spatula or curet, we may find gonococci. 

Secondary Gonorrheal Vaginitis. — Gonorrheal vaginitis is 
usually secondary and due to the irritation produced by cocci 
sent out from the cervix and uterus. Rarely do the cocci invade 



GONORRHEA IN ADULTS 39 1 

the wall and multiply. Gonococci, however, may develop in the 
vagina, in the squamous epithelium, but as a rule they do not go 
deep. It has been shown that individual characteristics and not 
alone the squamous character of the epithelium play an important 
role. The vaginal epithelium in younger women, in gravidas, in 
women with tender skin, lends itself more readily to gonorrheal 
vaginitis because of the succulence of the mucosa and the thinness 
of the epithelial layer. 

Primary Gonorrheal Vaginitis. — Primary gonorrheal vagini- 
tis does occur; it has been noted even after total hysterectomy. 
The vagina is hot, shiny, red, swollen, and bleeds easily. It is 
covered with pus or fibrin, under which are red, eroded areas. 

In chronic vaginitis the mucosa is thickened, the folds are promi- 
nent and covered with granulation spots. There is erosion of the 
cervix or else eroded or swollen mucosa is found in the posterior 
fornix. Sometimes as the end-result of a vaginitis chronica we get 
a condition resembling psoriasis, characterized by a thick, hard, 
dry, white mucosa. 

Treatment. — In acute localized vaginitis the patient should have 
rest in bed, the external genitalia should be thoroughly cleansed, 
cool or tepid sitz-baths may be taken daily. Alternate douches of 
bichlorid of mercury, i : 2000, and acetate of aluminum, 1 dram to 2 
quarts of water, should be given four times daily and gauze soaked in 
1 : 5000 bichlorid or in 1 per cent, acetate of aluminum should be 
applied to the perineum and vulva. Internally bromids and opium 
may be administered. When the primary inflammation and sensi- 
tiveness are diminished douches of bichlorid of mercury or \ per cent, 
carbolic acid are of value. If the vagina is not too sensitive, it 
should be washed, with the aid of a Ferguson speculum, with 
sponges soaked in a carbolic solution, and gauze soaked in 1 to 5 
per cent, protargol should be introduced into the vagina and left 
in place for several hours. Still later the vagina must be bathed, 
with the aid of a Ferguson speculum, by solutions of nitrate of silver 
1 to 5 per cent., and the vagina should be gently packed with sterile 
gauze or iodoform gauze left in place for twenty-four hours. 
Then irrigate daily with alum 2 per cent, or permanganate of potash 
1 : 1000. In the chronic persisting forms of vaginitis the Ferguson 



392 MEDICAL GYNECOLOGY 

speculum should be used and nitrate of silver should be thoroughly 
applied in very strong solutions (Figs. 36, 38). 

In very chronic cases if silver 1 per cent, or stronger fails, paint 
the vagina every two to three days with tincture of iodin or silver 
5 to 10 per cent, and pack the vagina with iodoform gauze for 
twenty-four hours. Continue the treatment till the vaginal epithe- 
lium desquamates. Douches should then consist of tannic acid, 
sulphate of zinc, or alum, 1 dram to the, quart. Splendid results 
are to be had by bathing the vagina, with the aid of the Ferguson 
speculum, with corrosive sublimate 1: 100 rendered acid by adding 
a few drops of hydrochloric acid. Then pack with iodoform gauze 
for twenty-four hours and repeat twice a week. In the mean 
time irrigate with 1 : 5000 to 1 : 2000 bichlorid. In that chronic 
form known as colpitis granulosa, first clean the vagina with the 
aid of the Ferguson speculum, and then use pyroligneous acid in 
the Ferguson speculum, rubbing it well into the vaginal mucosa 
with cotton sponges. This should be done two or three times a 
week. Between treatments astringent douches are taken. 

The following represents Finger's treatment of gonorrheal 
vaginitis : 

Acute vaginitis is often overcome by the use of cleansing douches, 
but the subacute and chronic forms are often stubborn. 

In the early acute stages we make use of rest in bed, care of the 
bowels, cool sitz-baths, and cold applications to the genitalia and 
the perineum. Diet should be mild and non-irritating. Bromids, 
chloral hydrate, and morphin control the nervous symptoms. 

So soon as instruments can be introduced into the vagina the 
vaginal mucosa should be cleansed by tampons with the aid of the 
Ferguson speculum. The vaginal wall is then washed or bathed 
with largin or protargol 3 to 5 per cent, or 1 to 2 per cent, perman- 
ganate of potash. 

When the subacute stage is reached, and especially in treating 
vaginitis granulosa, there is used, in addition to the permanganate 
of potash, every second or third day, 1 per cent, silver solution for 
bathing the vagina. After each vaginal bath a tampon or gauze 
soaked in 5 per cent, largin glycerin solution should be introduced 
into the vagina. 

This method of treatment should be carried out twice a dav. 



GONORRHEA IN ADULTS 393 

If the treatment, however, must be carried out by the patient, 
douches must be used consisting of 2 to 5 per cent, largin, 1 per 
cent, permanganate of potash, 1 per cent, sulphate of zinc, 2 per 
cent, alum, 5 per cent, ichthyol, or 2 per cent, argonin. Such 
douches should be taken three times a day and consist of two quarts. 
In such cases as must treat themselves with douches, every third 
day a vaginal bath should be given with 1 per cent, silver or tinc- 
ture of iodin. 

In the treatment of stubborn subacute vaginitis the vagina 
must be bathed daily with the above-mentioned drugs and the 
vagina must be tamponed. This treatment is continued for several 
successive days until the mucosa begins to be cast off. Then 
bathing is stopped and the above-mentioned irrigations are used 
daily until regeneration of the mucosa takes place. If then a 
normal mucosa does not result, the same treatment must be at- 
tempted over again. Schwarz recommends the following method: 
The vulva and vagina are cleansed with 1 : icco corrosive 
sublimate, then the vagina is energetically washed and rubbed with 
1 per cent, corrosive sublimate with the aid of the Ferguson specu- 
lum, and the vagina is tamponed with iodoform gauze. This 
process is repeated in three days, and three days later the tampon 
is removed, and for the next two weeks douches of 1 : 2000 corro- 
sive sublimate are taken twice daily. 

Sanger makes use of corrosive sublimate. In order to aid the 
action of the corrosive sublimate, he introduces into the vagina a 
tampon soaked in tannic glycerin. The next day the vagina is 
cleansed with soap and water, and then with the aid of a Ferguson 
speculum is thoroughly bathed with corrosive sublimate 1 : 500 
to 1 : 1000. Then a tampon soaked in iodoform- glycerin is intro- 
duced. In stubborn cases the vagina is also painted with tincture 
of iodin. 

In the treatment of cervicitis Finger, when the acute stage is over, 
paints with the aid of a Playfair sound with 5 to 10 per cent, 
solution of protargol, and later with strong silver nitrate or tincture 
of iodin. Erosions of the vaginal portion heal rapidly with this 
treatment and healing is aided by occasional painting with 5 per 
cent, acidum trichloraceticum. 



394 MEDICAL GYNECOLOGY 

CERVICO-UTERINE GONORRHEA 

In acute infections of the cervix the gonococci pass between the 
epithelial cells down to the connective tissue of the mucosa. There 
is a great infiltration with leukocytes, which wander up to the sur- 
face through the epithelium. In isolated areas the epithelium is 
gone or replaced by a layer of flat or round cells. In other areas 
there is a beginning formation of squamous cells. Nowhere does 
the process seem to extend markedly into the gland lumina. 

In acute cervical gonorrhea the portio, when seen through the 
speculum, looks swollen, and its covering appears shiny and red. 
The cervical mucosa projects as two dark-red, lip-like protrusions. 
There is a discharge of greenish-yellow pus. The posterior 
fornix of the vagina is often red. Follicles of the portio may 
be purulent. Marked subjective symptoms are generally absent. 
Patients complain only of the discharge and of burning in the vulva. 
There is some feeling of weight in the pelvis and dull pains in the 
back. Gonococci are found by microscope. 

In acute gonorrhea the cervix is red and swollen. There is 
e version and protrusion of the mucosa. The mucosa bleeds easily. 
There may be erosions or ectropion. Later the secretion is 
milky, mucoid in character, or only cloudy mucoid. Even in a 
clear mucoid discharge gonococci may be found. 

Acute gonorrheal endometritis represents an acute inter- 
stitial inflammation with small- celled infiltration. In acute gon- 
orrhea of the uterus the cervix looks swollen, shiny, and red. 
If uterine involvement occurs after the cervix infection is better, 
the latter often lights up again. Pressure in the fornix, on the 
portio, and bimanual examination cause pain. The symptoms 
are weight in the pelvis, discharge, sensitiveness to jars, pain in 
the pelvis and back, constant discomfort in any position, a sensa- 
tion of pulsation, and often temperature. The sooner after the 
cervix infection the uterine infection occurs, the worse are the 
symptoms. They are less if the infection extends gradually into 
the uterus or if it passes into the uterus after the cocci have become 
less virulent and then wake up after labor, or abortion, or curetting. 
Attacks limited to the uterine mucosa may subside quickly and the 
acute symptoms disappear. 



GONORRHEA IN ADULTS 395 

Acute metritis comes from acute infection. It is an active 
process. There are chills, fever, dull pain in the pelvis. The 
patient seeks her bed. Often the tubes, ovaries, and peritoneum 
are affected, with or without the production of exudates. Chronic 
metritis may result from such an acute metritis or it may be sub- 
acute from the beginning. This is especially so in young married 
women infected from a supposedly cured gonorrhea by cocci of 
diminished activity. There is then a gradual onset of pain in the 
back and pelvis, especially at menstruation. There is cervical ero- 
sion or ectropion of the cervical mucosa. Exacerbations occur with 
abortion and labor. Acute metritis demands rest in bed for weeks. 

Point of Location in Acute Gonorrhea. — In acute cases of 
gonorrhea, according to Bumm, the urethra is affected in 90 per 
cent.; the cervix in 40 per cent.; the glands of Bartholin in 12 
per cent. In one hundred patients of Bumm's, however, in whom 
the cervico-uterine infection was at least five months old, only six 
had just a chronic urethritis with gonococci; thirty-seven had 
gonococci in the cervix and urethra; fifty-seven had gonococci in 
the cervix alone. Of the ninety-four cases whose cervico-uterine 
secretion contained gonococci, fifty-one had symptoms which 
indicated an infection of the uterine mucosa and forty-three had a 
more or less clear pelvic peritonitis with disease of the adnexa. 
The proportion in these hundred cases is not a criterion in general, 
for many patients with a fresh but non-virulent infection of 
the urethra or cervix do not consult a physician. Of seventy-four 
other cases observed by Bumm from the very beginning, for 
periods of five months to a year or more, 97 per cent, had urethritis, 
70 per cent, had an affection of the cervix, 23 per cent, an in- 
volvement of the corpus of the uterus, and 10 per cent, tubal 
disease. It must be remembered, however, that tubal involvement 
often comes on months or years later and is of milder form. 

Chronic Gonorrhea. — Bumm says that in chronic cervical 
gonorrhea the glands of the cervix are not affected. He examined 
five uteri, the seat of chronic gonorrhea, which were removed by 
hysterectomy for salpingitis. He found that in chronic cervical 
gonorrhea the glands are intact and that the epithelium is almost 
normal. Cocci are present only where the epithelium is gone, 
and at these points there is a great round-celled infiltration under 



396 MEDICAL GYNECOLOGY 

the epithelium. The cocci do not extend into the connective tissue. 
Round-celled infiltration is observed wherever cocci are present, 
and superficially at these points there is a coating consisting of pus 
cells and coagulum. Gonococci are found in the metaplastic 
epithelium, but the epithelium of the glands is immune, just as 
Bumm claims is the case with the glands of Bartholin. Chronic 
cervical gonorrhea represents, therefore, an invasion limited to 
certain small areas. Gonococci are found in the metaplastic epithe- 
lium and thence mix with the secretion. The regenerated cylin- 
dric epithelia seem to be immune to the cocci. Therefore no deep 
action would seem to be necessary to destroy these invaders. 

Chronic Gonorrhea of the Uterus. — Of eighteen uteri removed 
by Wertheim for gonorrheal disease of the adnexa, in eight gono- 
cocci were still present in the secretion of the uterus. He found gon- 
ococci in groups on the epithelium, in the interepithelial spaces, 
and likewise in the subepithelial tissue. He observed a change 
to squamous epithelium and a huge infiltration with round cells 
and leukocytes. Macroscopically such uteri are enlarged, the 
wall is thickened and hard, and the mucosa is thickened to 5 mm. 
There is edema of the interstitial tissue. The mucosa is hyper- 
trophied. In one-half of the cases there is also glandular endome- 
tritis. (Doderlein uses this observation as an argument against 
judging of the etiology of endometrial changes from findings by 
the microscope.) At any rate, the interstitial changes are present. 

In chronic gonorrhea of the mucosa, according to Bumm, the 
invasion is localized to the upper layers. The outpour of leuko- 
cytes and the rich cell infiltration of the interglandular connective 
tissue represent to him a "distant action of the cocci." Bumm 
says that the invasion of the muscular layers by round-celled 
infiltration is not caused, as Wertheim says, by the entrance of 
cocci into the muscle bundles. In a uterus with chronic endome- 
tritis and pyosalpinx he believes there is enough chronic irritation 
and hyperemia to produce such round-celled groups. (He evi- 
dently insists on his theory of superficial action.) 

Gonococci were also found in the uterine wall in the above 
cases of Wertheim, just as bacteria are observed there in puerperal 
endometritis. In many cases there was infiltration of the muscu- 
lar tissue, growth of the vessel walls, and hyperplasia of the con- 



GONORRHEA IN ADULTS 397 

nective tissue. Wertheim believes the gonococci to be present in 
the inflammatory infiltrations in the muscle tissues. 

Symptoms of Chronic Gonorrhea. — Chronic gonorrhea of 
the uterus, if superficial and limited to the uterus, causes few 
symptoms. In fact, there may be only a slight secretion, dis- 
coverable only by the use of a Schultze tampon (Fig. n). There- 
fore we find many cases of unrecognized gonorrhea of the tubes 
whose only symptom is sterility. If the involvement is deep, there is 
then chronic metritis. The uterus is large, hard, and the mucosa is 
hypertrophied. There may be much discharge. In my opinion 
bleeding, when a symptom, is due to the end-changes in the 
uterine wall and not to early changes in the mucosa. Conservative 
treatment may cause great improvement, and then overexertion, 
abortion, curetting, etc., may cause a return of the fluor, with other 
symptoms. 

Wertheim took five patients with fresh gonorrhea in whom the 
adnexa were normal and in whom there were no subjective symp- 
toms of an affection of the endometrium. He curretted particles 
from the corpus mucosa and examination of the sections divulged 
gonococci in them all. Neither the internal os nor the isthmus of 
the uterine part of the tube stops the course of the gonococci in an 
apparently localized cervical gonorrhea. 

Diagnosis. — When gonorrhea of the cervix and uterus becomes 
chronic the discharge becomes less, and then mucoid or mucopuru- 
lent and mixed with many squamous epithelia which may contain 
cocci. When this occurs, the prognosis is doubtful, for the cocci 
may disappear for weeks and then reappear. Chronic gonorrhea 
is very hard to diagnose because of the absence of characteristic 
symptoms, especially so if limited to the cervix. The only symptom 
is discharge, which is mucoid, sometimes yellow or green, yet, 
according to Bumm, it may even be clear when gonococci are 
present. 

Doderlein's observation that gonorrheal endocervicitis and 
endometritis are often hard to determine is justified. A bright red 
external os is of as great significance as erosions, which are often 
present. On the other hand, erosions may be absent. There is 
frequently just a slight eversion of the mucous membrane at the 
external os. The discharge, if clear, may change after menstrua- 



MEDICAL GYNECOLOGY 

tion and become yellow for a short time. This same change 
may take place with congestions or after the use of silver. Chronic 
localized cervical gonorrhea causes so few symptoms that it is 
generally an accidental discovery. The presence of salpingitis in 
nulliparae, if appendicitis, tuberculosis, and sepsis be excluded, 
is of great importance. The period at which the symptoms first 
occurred is a point to be learned, for these evidence themselves not 
infrequently within a short period after marriage or soon after a new 
infection in the male. 

Acute gonorrhea comes from acute gonorrhea in man. Acute 
vulvovaginitis and urethritis are associated with profuse purulent 
secretion, intertrigo, and sometimes with Bartholinitis. The 
vulva is red. If the infection extends upward, we get metritis 
with fever, pain in the pelvis and back. There is increased size of 
the uterus, a sensitive uterus, and pus, or pus and blood, from the 
uterus. In virulent cases there are exudates in the pelvis, in the 
tubes, in the ovaries, occurring through parametritis and perime- 
tritis and perisalpingitis and peritonitis. 

Latent gonorrhea produces the following picture: After 
marriage there is noted increased leukorrhea, especially at men- 
struation. There is burning and pruritus in the vulva. There 
is dull pain in the pelvis and back, which is increased by exer- 
tion. Colicky pains occur before menstruation. Pregnancy often 
ends in abortion, and perimetritis and perioophoritis occur. 
Then the symptoms grow worse and are increased by danc- 
ing, exertion, coitus. Acquired dysmenorrhea occurs before 
or during menstruation. There may be irregular menstruation. 
The patient becomes thin, looks bad, is nervous and hysterical. 
Examination shows increased secretion from the genitalia. The 
outlet of the Bartholin ducts is red. There is a glassy or milky 
secretion from Bartholin's glands, obtained by pressure. There 
is redness about Skene's glands. There is redness near the small 
labia. 

Condylomata may be found on the posterior commissure or 
about the anus. The vagina perhaps is a little red. The portio 
is thickened, the cervical mucosa is red, and ectropion or erosions 
are observed. The increased secretion from the cervix is some- 
times not pathologic in appearance, but oftentimes purulent or 



GONORRHEA IN ADULTS 399 

mucopurulent. The uterus is lengthened and sensitive. Perime- 
tritis and parametritis are often present. The ovaries are enlarged 
and sensitive. Such conditions result from continued infection in 
the female by non-active gonorrhea. 

Gonorrhea with no Clinical Symptoms. — Gonorrhea in the 
female with no clinical symptoms is frequent. Neisser has called 
attention to the fact that puellae publicae may show none of the 
clinical symptoms, no redness, no swelling, no purulent secretion 
from the vagina, uterus, or urethra, and yet may shelter gonococci 
which produce infection per coitum. 

According to Finger, Laser examined the cervical secretion in 
sixty-seven puellae publicae and found gonococci in twenty-one. 
Of these twenty-one, only four had clinical symptoms of cervical 
catarrh; the other seventeen, from the clinical standpoint, could be 
considered normal. Three hundred and fifty-three examinations 
of urethras showed one hundred and twelve to contain gonococci. 
Of these, in ninety-one there was no secretion from the urethra; 
in sixty-one there were no clinical symptoms of urethritis. In 
10 per cent, of puellae publicae with only mucoid uterine secretion 
Welewski found gonococci. 

This shows the necessity for bacteriologic examination. This 
is especially necessary after the acute stage is over. In some 
cases gonococci are easily found for months and years. This 
occurs in patients who have infection of acute nature and shows 
an especial sensitiveness and susceptibility on the part of such 
patients. 

Schiller and Brose in two hundred and thirty- five cases of chronic 
gonorrhea found, according to symptoms, that the urethra was. 
affected in one hundred and eighty-one, the cervix in two hundred 
and sixteen, and the adnexa in one hundred and thirty-nine; 
yet they found gonococci in only 45 per cent, in the urethra and in 
32 per cent, in the cervix. 

Bumm, in one hundred women suffering for at least five months, 
found gonococci in the urethra forty- three times, in the cervix 
ninety-four times. In seventy-four women observed by Bumm 
for from five months to one year, he found the urethra affected in 
95 per cent., the cervix in 70 per cent., the endometrium in 25 per 
cent., and tubal gonorrhea in 10 per cent. 

In the acute cases the microscope shows gonococci in the proto- 



400 MEDICAL GYNECOLOGY 

plasm of the pus cells and in groups on the epithelial flakes. In 
chronic cases it often takes several examinations to find the gono- 
coccus. In very many cases they cannot be found at all. Pus or 
mucopurulent discharge from the glands of Bartholin means 
gonorrhea. Simple redness of the ends of the ducts, the so-called 
maculae gonorrhceicse are not considered by Bumm enough for the 
diagnosis, but redness plus pus is sufficient. Abscess of the 
glands of Bartholin, however, is almost surely gonorrheal. A 
granular vaginitis speaks for gonorrhea. The presence of cervical 
erosions and condylomata is a valuable sign. Corroborative but 
not certain diagnostic points are furnished by a mucopurulent 
infection of the cervix plus a urethritis. The latter furnishes a 
more or.less continuous discharge from the urethra, the presence of 
threads in the urine, etc., but a chronic inflammation of the urethra 
is often evidenced simply by a milky secretion, which can be ob- 
tained only if the patient does not urinate for several hours. With 
a gonorrheal cystitis we have an acid urine. 

The diagnosis of the chronic form is difficult, for often no gono- 
cocci are to be found. Sanger looks for acute or chronic gonorrhea 
in the male. Purulent catarrh with other causes excluded is of 
importance. Inflammation of the Bartholin glands and the presence 
of maculae are to be looked for. Condylomata are important 
diagnostic aids. 

A purulent or mucopurulent discharge from the cervix and 
evidences of inflammation of the adnexa and the peritoneum are 
most valuable diagnostic points. 

Treatment. — In the acute stage rest is most important. Cold 
applications or the rubber coil are applied to the abdomen. If peri- 
toneal irritation is present, an ice-bag is used. The intestines are 
emptied by enemata and opiates are given. If there is much dis- 
charge, cool vaginal bichlorid douches are given under low pres- 
sure. When there is high fever and little discharge, intrauterine 
irrigations with a double-running irrigator are permitted in post- 
partum and abortion cases if the adnexa are free of inflammation. 
With the double-running catheter i to 2 quarts of various mild 
antiseptic solutions are used and at a temperature of 70 to 8o°. 

In the subacute stage when the fever has ceased, instead of re- 
newed cold applications to the abdomen, a stimulating application 
in the form of a Priessnitz bandage is used every night. Tepid 



GONORRHEA IN ADULTS 401 

vaginal douches are given, and sitz-baths at the bedside, of a tem- 
perature of 70 to 85 and lasting five minutes, are sometimes 
ordered. Rest in bed for six to ten weeks is important. 

In the chronic stage of gonorrheal endometritis as much as possi- 
ble should be attempted without intrauterine treatment. By in- 
creasing the circulation in the uterus, increasing the tone of the 
myometrium, and thorough douching away of the discharge from 
the vagina, the condition can be markedly benefited and cured, espe- 
cially if the disease is not intraperitoneal. If there is no purulent 
inflammation of the adnexa or parametrium or perimetrium, this 
is accomplished by hot douches given with large amounts of fluid, 
by hot sitz-baths lasting half an hour, and especially well by carbo- 
nated salt baths. Discharge of the secretion is aided by suction 
and by glycerin and gauze vaginal packing (Figs. 13, 88). This 
may be followed later by local treatment of the cervix, combined 
with the cold water vaginal irrigation cure. This consists in daily 
douches of 8o°, gradually cooling subsequent douches down to 6o°. 
If bleeding is a symptom, several douches with 1 to 2 quarts of 
hot water should be given daily. If this does not help, and if 
the adnexa are free, the use of local medical treatment and irriga- 
tion of the uterus is advised by many. Although I personally 
disapprove of these methods in the vast majority of cases, I shall 
mention them. 

In gonorrhea of the uterus, Joseph washes the cervical canal 
three times a week, with the aid of the speculum, with protargol 
i to J per cent., albargin J per cent., largin J to 1 per cent., ar- 
gentamin 1 : 1000. He advises daily irrigations with a double- 
running catheter, using one quart of bichlorid of mercury 1 : 5000. 
He introduces into the cervix with Playfair sounds 20 per cent, 
chlorid of zinc or 4 per cent, formalin and packs the vagina with a 
glycerin preparation. If the gonococci continue to be present 
in the cervical secretion, the condition has probably extended into 
the uterus. He then uses the Braun syringe and injects into the 
uterus every three to four days a mixture recommended by Asch, 
which consists of: 

1^. Alumnol 5ij 

Lanolin § iij 

Aq. dest. 

Give aa 3 vj 

26 



402 MEDICAL GYNECOLOGY 

Or else he irrigates the uterus with a double-running catheter, 
using a 5 per cent, solution of ichthargan, or else he introduces 
25 per cent, protargol suppositories into the uterus. Suppositories 
3 to 4 inches long and J to f inch in diameter can be readily made 
by any druggist with a base of cacao-butter. They are of value in 
a base of 95 per cent, glycerin and 5 per cent, stearic acid, or in a 
base of boroglycerid and gelatin. These two forms demand a 
special piece of mechanism for their manufacture. Protargol 
suppositories with these bases (protargol up to 2 per cent.) are sold 
by various wholesale drug firms. 

Finger speaks for radical treatment of gonorrheal endometritis 
to avoid extension to the tubes. After the acute stage is over 
irrigations and instillations are used, with or without previous 
dilatation of the cervical canal. After the first acute stage is over 
Sanger recommended irrigations with corrosive sublimate com- 
bined with 2 per cent, chlorid of zinc solution or creolin or creosote. 
At times he applies locally 10 per cent, chlorid of zinc. Sinclair 
recommended the application of tincture of iodin on two or three 
successive days, which is followed after the discharge of a mem- 
brane by renewed application. 

Schwarz recommends copious irrigations of the uterus with 
1 : 5000 to 1 : 2000 bichlorid or 1 to 2 per cent, carbolic. 

Finger introduces into the cervix on a Play fair sound, 5 to 10 per 
cent, protargol or ichthargan, and in chronic cases tincture of iodin 
or 5 per cent, acidum trichloraceticum. Siredey recommends 1 
per cent, picric acid. 

When gonorrheal infections extend up into the higher areas of 
the uterus, as a rule they do so (1) as a result of injury, such as 
excessive coitus, which means congestion and continued infec- 
tion; (2) through work or effort; (3) during menstruation. I do 
not practice intrauterine treatment, for it injures the tissues, aids 
the deep entrance of the cocci, and extends the infection. No ap- 
plicators and no sounds should be used. Treatment should con- 
sist of rest, sitz-baths, vaginal packings, and douches. Protargol, 
dilute bichlorid, and ichthyol solutions are the best. The cases 
which are hardest to cure are those where the mucous membrane is 
changed to squamous epithelium and the discharge consists mainly 
of squamous epithelia. 



GONORRHEA IN ADULTS 403 

In treating cervical gonorrhea Bumm makes incisions in the 
external os, if it is narrow. When the incisions are healed, he 
clears the cervix of mucus and applies i to 5 per cent, silver nitrate 
at one sitting, until the whole lining becomes white. Ichthyol 5 
to 10 per cent, is then applied on cotton or gauze. When the result- 
ing membrane finally comes away, he repeats the cauterization 
with silver or with chlorid of zinc, and ofttimes the case gets well. 
If it does not heal or if there are signs of endometritis, he treats 
the uterus carefully unless the adnexa have been recently affected. 
If this is the case, he lets even the cervix alone, for care should be 
taken to avoid extension to the tubes. 

He begins intrauterine therapy, even with women who have had 
children, with dilatation of the internal os by laminaria in order to 
get good drainage. Then he swabs out the secretion and applies 
1 per cent, silver or 1 to 3 per cent, ichthyol with Playfair sounds 
covered with cotton. He makes the application for ten minutes. 
Injections with a syringe are not advisable. He also uses daily 
irrigations with a double-running catheter for fifteen minutes to 
wash out all the folds of the endometrium. He uses silver 1 : 1000 
or ichthyol 1 : 100. Sometimes the cocci disappear very soon, but 
sometimes they reappear after treatment is stopped, in which event 
treatment must be continued for weeks. 

When there is a chronic uterine gonorrhea with many squamous 
epithelia in the secretion and cocci in groups on the epithelia, 
stronger solutions must be used, such as tincture of iodin, silver 
10 to 20 per cent., or strong chlorid of zinc. The resulting strong 
reaction after such a thorough cauterization, which should be done 
only once a week, throws off the cocci. If fever occurs on the day 
of treatment or if there is increased sensitiveness of the uterus, 
treatment should be stopped for a while. (Bumm.) 

While for a time the gonococcus infection may remain limited 
to the cervical mucosa, it must be admitted that it is extremely 
difficult to tell in some patients when the invasion has encroached 
upon the uterine cavity. Boldt has, therefore, placed himself on 
the side of those who at once attack the entire uterine mucosa. If 
the patient permits it, he puts her under an anesthetic and disin- 
fects the genital tract, and then, before proceeding to dilate the 
cervical canal, the uterus is copiously irrigated with a double-current 



404 MEDICAL GYNECOLOGY 

catheter; then the cervix is dilated slowly and gently, but effec- 
tually, and a thorough curettage is done with a sharp curet, pre- 
ferably a Martin curet for the first general abrasion of the mucosa, 
followed by a small sharp curet used around the tubal openings. 
The uterus is then again copiously irrigated with plain sterile 
water or a mild antiseptic solution, and is tamponed with a long 
strip of gauze soaked in 5 per cent, solution of soluble silver 
(protargol). The rest of the genital tract is tamponed with iodo- 
form gauze and the patient put to bed. If urethritis is still present, 
it should be treated at this time, and also the ducts if infected. 
The gauze is removed on the following day, and on the third day 
the entire treatment, with the exception of the curettage, is repeated. 
If consent to curettage is not given, office treatment is used. An 
intrauterine application is made by means of the intrauterine 
applicator syringe. The intrauterine tampon is left in the uterus 
for two or three hours and the patient directed to remove it by 
means of the attached strings. A medicated tampon is placed in 
the upper part of the vagina, if desirable, and is held in place by a 
plain non-absorbent wool tampon. The strings of the tampon 
are so marked that the patient should know which to remove first. 
After removal of the tampon a copious antiseptic douche is used 
by the patient. This treatment is not as desirable as the first, 
as it is fraught with more risk of causing subsequent pelvic inflam- 
mation . The treatment should be repeated every two or three days, 
and the advantage of a perfectly made intrauterine applicator 
cannot be overestimated (Figs. 51, 52). 

In cases of menorrhagia complicating gonorrheal endometritis, 
Boldt finds patients benefited by the internal administration of 
cotarnin hydrochlorate (stypticin), in dose of 3 grains given in gela- 
tin capsules three times daily, if the previously instituted treatment 
does not have the desired effect. Alone, without local treatment, 
especially curetting, he finds that it gives unsatisfactory results. 

In that class of patients in whom metrorrhagia and menorrhagia 
are almost uncontrollable, he awaits a non-bleeding period, and then 
makes intrauterine applications of pure carbolic acid, leaving the 
intrauterine tampon in situ for a couple of hours. The treatment 
is repeated every second day until six or eight treatments have 
been applied, and at the end of the next menstrual interval it should 



GONORRHEA IN ADULTS 405 

be repeated. He has had no untoward results from the applica- 
tion of pure carbolic acid to the uterine cavity. 



GONORRHEA OF THE TUBES, OVARIES, AND PERITONEUM 

The tubes may be affected by a rapid upward extension of an 
acute gonorrheal infection in the space of a few days. Only the 
virulent cases cause early symptoms, because they affect the whole 
tube up to the external ostium. An invasion of the tubes, if rela- 
tively acute, and if accompanied by peritoneal lesions, is generally 
recognized as a peritoneal involvement. Acute cases have fever, 
due to involvement of the deeper structures of the uterus, of the con- 
nective tissue, and of the peritoneum. There is then pain, tender- 
ness, slight rigidity, sometimes slight abdominal distention and 
pain, and colicky pains which are not due to the tubal affection 
but to the associated metritis. 

Acute Salpingitis. — There are cases of gonorrheal salpingitis 
in which adhesions are very readily formed and the exit of pus is 
limited without marked involvement of the peritoneum taking 
place. There are other cases in which the pus is poured out rapidly 
and in large amounts or else adhesions do not form readily, in 
which the amount of purulent discharge into the peritoneal cavity 
is so great that a more extensive peritonitis takes place, and in 
several well-authenticated cases a so-called general purulent 
gonorrheal peritonitis has resulted. 

The peritoneum is not an epithelial tissue and is much more 
resistant to the invasion of the gonococci than mucous membrane. 
A predisposition is necessary, and this often consists in a mechan- 
ical injury or irritation. In gonorrheal pelveoperitonitis the 
serosa of the pelvis, of the uterus, and of the adnexa are highly 
injected and covered with a layer of cloudy, pus-like fluid, which is 
also present in the sac of Douglas. This exudate contains pus 
and intracellulur gonococci. The posterior surface of the uterus 
and the ligamenta latum of either side are covered with this white 
membrane, which can be lifted off in small pieces. The serosa, 
thus uncovered, is rough, dark red, and looks like eroded tissue. 
These membranes prove to be composed of pus cells, fibrin, and 
intracellular gonococci. Out of the abdominal end of either tube 



406 MEDICAL GYNECOLOGY 

comes a white creamy pus containing gonococci. The tubes and 
ovaries are swollen and congested, having a dark blue, almost 
gangrenous look. 

The degree to which the peritoneum is irritated, and especially 
the degree to which closure of the abdominal end, with the forma- 
tion of adhesions, takes place, is of the greatest variability. Tubes 
may heal and pregnancy may take place, so long as the ends are 
not permanently closed, and especially if they are not covered by 
adhesions. 

Pyo salpinx. — With these acute attacks, if the outer ends are 
closed or if adhesions take place at once, acute pyosalpinx may 
result. We may see this condition resulting in a one-sided pyosal- 
pinx, while the other tube may seem normal. Such patients gener- 
ally remain sterile, and at a later period the other side may 
become affected, but not to the degree observed in the earlier acute 
involvement. 

Cases of chronic pyosalpinx with much pus accumulation are 
only too often the result of recurrent attacks brought on by exces- 
sive coitus, physical work and strain, intrauterine treatment, 
curetting, abortions, etc. Here a state of chronic invalidism may 
result, due to great adhesions involving the omentum, sigmoid, 
intestine, etc. If pus pours out rapidly from the tubes, especially 
in recurrent attacks, we get adhesions of a firm character. 

We may get infection of the peritoneum by the cocci passing 
through the tube wall. Orthman, Menge, and others failed to 
find gonococci in the wall of the tube, but Wertheim found them 
up to the peritoneum. Bumm thinks this to be rare. Wertheim 
believes that the cocci often pass through the tube wall into the 
peritoneal cavity, and in this way explains fresh recurrent attacks 
of pelvic peritonitis in cases where the tube ends are closed. Bumm 
says that the tube ends probably open by pressure from within 
the tube. 

Gonorrheal infection of a mild degree of virulence generally 
passes upward slowly before or especially after labor, curetting, or 
abortion. Recurrent mild attacks may be produced by intra- 
uterine treatment or by the curet, and these factors have most to 
do, in the subacute cases, with driving the inflammation up to 
the peritoneum and causing adhesions. Those cases of subacute 



GONORRHEA IN ADULTS 407 

gonorrheal infection which suffer the most pain have been so 
treated. 

The gonococcus may infect the ovarian follicles and may pro- 
duce ovarian abscess. The ovaries, however, may be slowly and 
mildly infected and become diffusely inflamed and adherent. 
The ripening of follicles is then made difficult; they often degener- 
ate into cysts and the ovaries are indurated. When so affected, the 
secretory activity of the ovaries is altered and menstruation may 
occur every six, eight, or ten weeks. 

Treatment. — The treatment of acute involvement of the tubes, 
ovaries, and peritoneum means rest in bed, attention to the bowels, 
the use of the ice-bag or ice-coil, and the usual methods of anti- 
pyretic treatment. Cool or tepid vaginal douches, under low pres- 
sure, of 1 : 5000 bichlorid of mercury should be given two or three 
times a day and the associated vulvitis or cystitis should be treated 
according to the manner explained in the sections dealing with gon- 
orrheal vulvitis and gonorrheal cystitis. Very careful vaginal or rec- 
tal examination should determine the character and extent of the 
involvement and the presence of a peritoneal exudate. In the 
vast majority of cases of gonorrheal peritonitis the condition is 
localized in the pelvis. A relatively small number of cases have 
been reported of general gonorrheal peritonitis. The prognosis 
is extremely good in all cases with conservative treatment. Only 
the cases of mixed infection associated with general peritonitis 
furnish a mortality. In cases of general peritonitis due to gonococci 
laparotomies have been done with favorable results. Conservative 
treatment, however, is sufficient, except when the diagnosis of the 
cause is doubtful. 

The following view of Bumm is not to be questioned: A 
gonorrhea freshly infecting a patient with adnexal disease means 
that the patient should stay in bed for two months and should be 
allowed to get up only when every bit of inflammation is gone and 
when, for four weeks, there has been absolutely no rise in tempera- 
ture. Treatment also includes sitz-baths, douches, glycerin 
tampons, and a "cure," but should be begun only months after 
the acute attack. A too early "cure" often starts up an extension 
of tubal trouble. 

In gonorrhea in pregnancy there should be no treatment except 



408 MEDICAL GYNECOLOGY 

perhaps douches, and the patient should stay in bed four to five 
weeks after labor, until complete involution takes place. 

Boldt says: "In acute gonorrheal infections of the adnexa, 
with or without invasion of the pelvic peritoneum, rest, the applica- 
tion of the ice-coil or ice-bags, a narcotic, preferably in the form of 
suppositories, for the purpose of lessening peristalsis, and the 
avoidance of subsequent local examination should be insisted on 
until the acute symptoms have subsided, when one may begin 
with warm vaginal douches containing a mild antiseptic. The 
cold applications should be continued until the temperature is 
normal and the patient is free from pain. The patient should not 
leave her bed until the temperature has remained normal for one 
week, and upon any exacerbation of symptoms the rest treatment 
should be resumed. 

"If at any time the Fallopian tubes become distended with pus, 
and sink to the floor of the pelvis, further delay with conservative 
treatment should not be practised. The patient should be anes- 
thetized and the cul-de-sac of Douglas widely opened. The tubes 
should then be incised and evacuated. There is a class of patients 
who, while they make a temporary recovery, have more or less pain, 
either constantly or at varying intervals, with menstrual irregulari- 
ties and perhaps occasionally acute exacerbations. Bimanual 
examination reveals evidences of salpingo-oophoritis with a 
metro-endometritis. The Fallopian tubes are more or less dis- 
tended, and sometimes the adnexa and uterus are matted together 
in the perimetric exudate. It may be impossible in these cases 
to demonstrate the presence of gonococci." In these cases local 
treatment has proved useless in Boldt's experience. For him, surgi- 
cal intervention is the only form of treatment that holds out hope. 

"There is another class of patients in whom the disease has to a 
large extent become spontaneously cured, so far as pyosalpinges are 
concerned, but the residue of the old chronic pelvic inflammation, 
consisting of tubes thickened and adherent, ovaries in a constant 
state of inflammation, and uterus perhaps smaller than normal, 
in some cases larger. Menstruation with this class of patients is 
likely to be at longer intervals — six weeks to three months ; though 
in some instances it may be frequent, at intervals of two or three 
weeks, and the amount of blood lost variable. Severe dysmenor- 



GONORRHEA IN ADULTS 409 

rhea may be present. Local therapy seldom benefits this class 
of women, who usually have been sterile or have but one child. 
If their suffering makes it difficult for them to pursue their voca- 
tion, and they are past the middle thirties, a radical vaginal opera- 
tion is most expedient. If younger, then a salpingo-oophorectomy 
should be resorted to." 



CHARACTERISTICS OF GONORRHEA 

For many years Bumm and Wertheim have been the leaders in a 
controversy concerning the relation of the gonococcus to the tissue 
on which it is implanted. Bumm assumes that in the vast majority 
of instances the gonococcus is a parasite growing on the superficial 
layers of the various mucosas. For instance, he states that in 
chronic cervical gonorrhea the gonococci are limited to isolated 
small areas of mucosa in which the gonococci are situated in meta- 
plastic squamous epithelium. The epithelium of the glands he 
believes to be generally immune, holding also to the belief that 
while the duct of Bartholin may be invaded by gonococci, yet the 
gland of Bartholin itself is not so affected. In the uterus he finds 
the mucosa affected, as a rule, in localized areas and only superfi- 
cially. On the other hand, Wertheim states that the gonococci 
may enter the subepithelial connective tissue in any case. 

There is no doubt that neither the contention of Bumm nor 
that of Wertheim forms an absolute rule. Different individuals 
react differently to the invasion of the gonococcus, and the amount 
of the discharge, the acuteness of the inflammation, the depth or 
extent of the invasion, the duration of the affection, and the results 
of treatment in the various forms of this inflammation differ mark- 
edly. Gonorrhea may be acute or subacute, it may be recognized 
or not, it may be localized or diffuse, it may be superficial or deep. 
These various combinations depend on the virulence of the gono- 
cocci, the susceptibility of the individual's tissues, the degree of 
congestion existing before infection, etc. 

The Light Form. — Bumm divides gonorrhea into a light 
form and a severe form. He says that the distinction is not due 
to a difference in the virulence of the gonococci, but to the element 
of localization. The light cases, says Bumm, are those in which 



4IO MEDICAL GYNECOLOGY 

only the cervix or urethra is affected. The severer cases are those 
in which the infection has extended above the internal os of the 
uterus or has invaded the posterior portion of the urethra. While 
this difference of localization does make symptoms light or severe, 
there is certainly a difference in the resistance of patients and in 
the virulence of the gonococci. 

The Severe Form. — In those cases which are acute from the 
beginning, and in whom there is an extension upward, or in 
whom recrudescences of the original acute attack recur, we find 
pyosalpinx, infiltration of the uterine wall, abscess formations, 
peritonitis, etc. In them, of course, the acuteness of the in- 
flammation attracts attention to the nature of the infection, and 
the subsequent annoyances of pain and sterility are readily under- 
stood. Many women, however, in whom upward extension has 
taken place, if the upward extension occurs late and is of a mild 
nature, suffer neither from pain nor sterility, or else from sterility 
alone. (The vast majority of cases of gonorrhea in women are 
acquired from a male urethritis or prostatitis which gives few or no 
symptoms, or from cases in which a chronic gleet has been examined 
by a physician who, finding no gonococci present, considered the 
patient, according to previously accepted standards, cured. This 
is the error which aids in the wide spread of gonorrheal infection 
of the female.) 

In further proof that the gonococci may enter the subepithelial 
connective tissue in any case, Wertheim has shown that they are 
found, for instance, in the subendothelial connective tissue of 
the peritoneum, in the bladder-wall, in the wall of the vagina. 
They have been found in the connective tissue of the synovia, in 
gonorrheal arthritis, in the tube walls, in edema of the foreskin, in 
myocarditis gonorrhoica, in endocarditis gonorrhoica. As a 
general rule, the gonococcus causes no pus in connective tissues, 
but can do so, as in ovarian abscess, periurethral and perichondrial 
abscess, in abscess of the uterine wall, in abscess of the cervical 
glands, abscess of the dorsum of the metacarpus, about the knee- 
joint, etc. As a factor in mixed affection the gonococcus has been 
found in cystitis, arthritis, Bartholinitis, parametritis, and in some 
cases of adnexitis. 

Characteristics of the Gonococci. — When growing on a 



GONORRHEA IN ADULTS 411 

mucous membrane, where new medium is constantly produced 
by continued secretion, the gonococcus thrives better than when 
encapsulated in an abscess, in which event the cocci may die, 
affected by their own toxins or by the action of other bacteria. As 
early as six weeks after an acute gonorrheal infection, gonococci 
were absent in a pelvic abscess which has been opened. Just as in 
a culture-medium colonies of gonococci die within one or two 
weeks if not transplanted, so the gonococcus in a chronic case 
becomes weakened in virulence so far as the affected individual 
is concerned. Being nourished, however, by continued secretion, 
it does not die, but becomes less virulent, adapts itself to the 
bearer, and a chronic or subacute inflammation results. Trans- 
plantation to fresh media prolongs the life of colonies of gonococci. 
When the gonococcus is removed from a gonorrheally infected 
region to a new area by the irritation of coitus, labor, exertion, or 
treatment, and especially if it is transplanted to a new individual, 
it produces a more acute inflammation. In the latter instance, 
if retransplanted again to the first bearer, it may cause a sharper 
inflammation on the basis of the chronic form (rule of Wertheim). 
Mixed Infection. — The gonococci pass down between the 
cement substance of the epithelial cells and therefore are not easily 
washed away. They pass down to the subepithelial tissues and 
generally stop there. For this reason gonorrhea is frequently a 
superficial process in the genito-urinary tract, but by no means 
always so. Wertheim and others have shown that gonococci may 
produce pus in the connective tissues. Bumm says that this is 
rare, and that it generally means a mixed injection. In acute 
gonorrhea the microscope shows gonococci alone, but cultures, 
he states, show other bacteria, especially those of the pyogenic 
form. These mixed inflammations, as he then views them, evidence 
the presence of the staphylococcus aureus or the streptococcus. 
According to Bumm, they change the original character of the 
gonorrheal infection and produce abscesses in the connective tissues, 
in the vulvar and urethral follicles, in the glands of Bartholin. 
They may produce purulent parametritis, pyemia, etc. He 
disagrees with Wertheim, because he believes in the superficial 
nature of the inflammation, but he acknowledges that metastatic 
conditions may occur in the joints, usually in the knee-joints, but 



412 MEDICAL GYNECOLOGY 

sometimes in all the joints. He also acknowledges the existence 
of endocarditis. We see, therefore, that gonorrhea may be acute 
or subacute, localized or diffuse, superficial or deep. 

Epidermis- like squamous epithelium offers great resistance to 
invasion by the gonococci. These cocci, however, readily pass 
through cylindric epithelium, even if of several layers. In the 
rectum, for instance, they grow down even to the muscularis. 
They may increase in connective tissue and cause an intense 
inflammation. The desquamation of epithelium mixed with poly- 
nuclear leukocytes coming from the capillaries produces a catarrh 
if there is an outlet to the discharge. If the outlet of a duct is 
closed by a drop of pus or by atresia, then pus accumulates in the 
gland (prostate, Cowper, Bartholin) and the periglandular tis- 
sue is invaded and a pseudo-abscess results. A real gonorrheal 
abscess may be produced by the gonococci in connective tissue. 
Such has been noted in muscle abscesses, subcutaneously near 
joints, in the perineum, in skin abscess, etc. Therefore such 
complications may occur through the action of the gonococci alone. 

However, other bacteria are found in gonorrheal pus. Staphylo- 
cocci are found in the pus of gonorrheal involvement of mucous 
membranes and in periurethral abscesses. Streptococci have been 
found in Bartholin abscess and in gonorrheal pyosalpinx. There- 
fore, in addition to complications occurring through the activity of 
the gonococcus only, there may occur mixed infections or secondary 
infections. In mixed infections the gonorrheal involvement of a 
mucous membrane furnishes a portal for the entrance of pus cocci. 
In secondary infections the gonococci cause a complication, and 
later pus cocci enter and supplant the gonococci, which disappear. 
Metastases by gonococci may occur through the lymph- channels 
or blood-channels. 

Extension of the Gonococci. — Wertheim says that isolated 
affections of the cervix are rare and that the infection extends up 
into the uterus more often than is suspected. Bumm, on the other 
hand, says that isolated cervical gonorrhea is of frequent oc- 
currence. It may later affect the uterus, in which event it pro- 
duces marked symptoms. He says that the internal os forms an 
obstacle, but if this point of limitation is overstepped, the symp- 
toms are much more severe. The causes which lead the cocci 



GONORRHEA IN ADULTS 413 

into the uterus are menstruation, overactivity, excess in venery, 
the use of the sound, the use of the curet, the puerperium, etc. 
After the gonococci pass the internal os they generally stop at 
the tubal ostia, but the same causes mentioned above may pro- 
duce an extension into the tubes, etc., for the gonococci of them- 
selves have no power of motion. 

Virulence of Gonorrhea. — This difference of opinion is to be 
reconciled by realizing that the virulence of a gonorrhea in the 
female depends on the character or virulence of the gonorrhea in 
the male at the time of the production of infection. A most im- 
portant fact is that on which Doderlein also lays stress. 

Doderlein says that acute gonorrhea in the female comes from 
acute gonorrhea in the male, and that subacute gonorrhea in the 
female comes from a chronic condition in the male. The latter 
has none of the symptoms of the acute form, often only presenting a 
discharge. There may be no pus cells in the male secretion, there 
may be only isolated cocci in the urethra or in the threads, and for 
that reason the gonococci are mixed with the seminal fluid, and 
rarely infect the urethra, but infect the cervix alone. Such light 
cases do not cause pyosalpinx, and by no means do they always 
cause sterility if no accessory irritation has taken place. (When 
gonococci are present in goodly number, we rind no other bacteria. 
As the gonococci diminish, other bacteria come into the field.) 

Changes Produced by Gonococci. — The characteristic change 
in gonorrheal infection is round-celled infiltration, and regeneration 
is associated with the formation of squamous epithelium. If 
squamous epithelium is found in a long-continued discharge, this 
change is of bad prognostic meaning. Chronic gonorrhea of the 
cervix and uterus, according to Bumm, means the presence of 
mixed bacteria together with the gonococci. In chronic cases the 
gonococci may remain on the surface of the new squamous epithe- 
lium. There is caused a light but steady secretion which may be 
increased by irritation, and the cocci may take on a new growth. 
Their presence in the pus cells does not represent phagocytosis; 
on the contrary, the gonococci eat up the protoplasm which is rich 
in peptone. They grow well on the surface. On the other hand, 
they die quickly in a closed pus cavity, as in an obstructed Bartho- 
linitis or in a pus tube. 



414 MEDICAL GYNECOLOGY 

Gonococci in Relation to Pregnancy. — Localized cervical 
gonorrhea does not affect conception. In chronic gonorrhea of the 
uterus Bumm sees no obstacle to pregnancy if the tubes seem 
normal. Even if the tubes are affected, they may subsequently 
return to the normal. On the other hand, it may be said that the 
tubes may be affected and yet seem normal on bimanual examina- 
tion. Bumm says that chronic gonorrhea in the second half of 
pregnancy generally goes on without symptoms. In the earlier 
months the presence of the gonococci may cause abortion or disease 
of the decidua. If gonorrhea is acquired during pregnancy, the 
infection remains in the urethra or cervix, but has a marked ten- 
dency to produce abscess in the glands of Bartholin. The gono- 
cocci always increase markedly during the post-partum period. 

Kronig examined one hundred and seventy-nine cases of puer- 
peral endometritis and found gonococci in the lochia of fifty. 
They increase in the first few days and then disappear entirely or 
gradually. Bumm says that while in the cervix of pregnant women 
cocci may be found only in small numbers, yet in the lochia from 
the cervix on the second to the fifth day post-partum they are 
found in huge numbers and the cocci are large and plump. Toward 
the third week of the puerperium they are hard to find if the secre- 
tion becomes mucoid. In some cases it is easy to find them for 
weeks if the secretion is not mucoid. In the early puerperium 
there is generally no fever and no symptoms. If there is tempera- 
ture, it is very low and lasts but two or three days. This is either 
due to an absence of extension or to a slow extension or to slight 
virulence. In the later puerperium, after the patients get up, 
there is observed a marked tendency to an ascending inflammation, 
as was first pointed out by Sanger. Then we get metritis, para- 
metritis, and salpingitis. Fever cases occurring late in the puer- 
perium with symptoms of localized peritonitis forebode gonorrhea. 
Many women go through several labors without an upward exten- 
sion from the cervix or even from the uterus. 

The pioneer in the field of gonorrhea in observing its wide 
spread among all classes of society is Noegerath, who set down 
his views in his work, "Die latente Gonorrhoe" (Max Cohn & 
Son, Bonn, 1872). According to Noegerath's original opinion, 
three out of five married women have gonorrhea, but he later modi- 



GONORRHEA IN ADULTS 415 

fied his figures. According to Kehrer, one-third of the sterile mar- 
riages are due to the male through azoospermia or oligozoospermia 
which can generally be referred to epididymitis. Bumm quotes 
E. Schwartz as saying that of one hundred men, ten carry a chronic 
gonorrhea into the marriage state, while ten more acquire a fresh 
gonorrhea after marriage, so that one woman in five becomes 
infected. Bumm says that, according to statistics, 12 per cent, of 
marriages are sterile. On the basis of Noegerath's figures, it 
would appear that 8 per cent, of all marriages are sterile through the 
gonococcus. One hundred and ten cases of primary sterility gave 
Bumm only 30 per cent, as due to gonorrhea. He says that very 
many women with cervical gonorrhea bear several children. Gonor- 
rhea, according to him, plays a greater role in the production of 
secondary sterility. When examinations are made by various 
observers in obstetric clinics, gonococci are found in pregnant 
women in from 12 to 30 per cent, of the cases. If we could add 
together (1) the cases of primary sterility in which spermatozoa 
are present in the male, (2) cases of secondary sterility (which are 
generally not included under statistics of sterility), (3) many 
cases of ectopic gestation, (4) cases of gonorrhea localized in the 
cervix in patients who are not sterile, (5) cases with gonococci in 
the lochia in whom sterility does not take place, (6) cases operated 
on for gonorrheal disease of the adnexa, and never classed under 
sterility, but called pyosalpinx, etc., I am sure we would agree that 
a very much larger percentage of women suffer from gonorrheal 
infection than is medically believed. 

Difference Between Gonococci and Pus-producing Cocci. — 
The gonococci differ in their activity from the pus cocci. The 
pus cocci enter tissues more intensively than do the gonococci. 
The pus cocci grow faster and make their way independently. 
The gonococci, being weaker, seek interepithelial passages, con- 
nective-tissue spaces, and cavities. They have less energy than 
the pus cocci. Gonorrheal inflammation is purulent. The 
gonococci cause much granulation tissue early and the inflam- 
mation becomes readily subacute. There is a tendency to the 
formation of connective tissue, resulting in scars and strictures. 
The gonococci are easily destroyed by high temperature and by 
fever. Therefore the gonococci, as compared with pus cocci,, 



416 MEDICAL GYNECOLOGY 

are weaker, more readily affected, and produce more benign acute 
processes. 

GONORRHEA IN THE MALE 

The secretion after a recent gonorrhea in the male con- 
tains shreds, which result from catarrhal desquamation of epi- 
thelium, and polynuclear pus cells held together by finely gran- 
ular mucin. Cloudy urine results from a diffuse catarrhal affec- 
tion of the mucosa and glands with degeneration of the epithelia. 
Shreds, pus, cloudy urine, signify a recent, still diffuse urethritis. 

The older the process, the slighter are the diffuse catarrhal 
changes, the less is the hyperemia, and the less is the mucus. 
Only localized areas then produce a secretion which consists of 
epithelial cells and pus cells held together by mucin and appearing 
as shreds. Shreds in clear urine signify chronic gonorrhea. If 
such a form is irritated, then catarrhal symptoms (hyperemia 
and production of mucus) start up again about the fixed chronic 
areas and then disappear. 

In acute purulent gonorrhea of the urethra in the male gono- 
cocci are present. In the chronic form it is often hard to find 
them in the shreds or in the "pus drop." One may examine 
for days and find various bacilli and cocci and no gonococci. 
If an exacerbation of the process occurs, then in the increased 
pus we may find gonococci easily, while the other cocci disappear. 
This disappearance is constant. In acute cases no bacteria, or 
very few bacteria or cocci other than the gonococci, are found. 
We can artificially produce an exacerbation by the use of silver 
nitrate or by irrigation with i : 20,000 bichlorid of mercury. 

There are cases of male gonorrhea where, in spite of frequent 
examinations continued for several weeks, and in spite of one or 
more artificially produced exacerbations, no gonococci can be 
found. The pus and shreds show no germs or else other germs, 
but no gonococci are present. We may come to the conclusion 
that the gonococci have disappeared, but that the changes pro- 
duced by their presence continue. In many cases of chronic 
gonorrhea examination of shreds shows no gonococci and no 
other germs. In some cases, even as early as the terminal stages 
of an acute gonorrhea, other micro-organisms are found in addi- 



GONORRHEA IN ADULTS 417 

tion to gonococci. This is often the case in chronic gonorrhea. 
Generally they are bacteria of various length and thickness. 
There are cocci in short chains and groups. These bacteria 
enter the urethra in coitus and grow on a diseased mucosa and 
may keep up a chronic stubborn catarrhal discharge (Finger). 

Streptococci, staphylococci, and bacterium coli have been 
found in shreds and in the secretion of the posterior urethra. 
These may infect the female and cause a cystitis and pyelitis. 

Views on Marriage. — Finger allows marriage after chronic 
gonorrhea (morning drop or shreds) "if repeated daily examina- 
tions of secretion and shreds show that these contain only epithe- 
lia and no pus cells, and if, after irrigation with silver or subli- 
mate, and the production of a purulent discharge, the discharge 
shows no gonococci. The absence of gonococci, the absence 
of pus cells, the absence of periurethral complications are essen- 
tials. So long as the secretion or shreds contain pus cells we 
know that inflammation has not ceased." While inflamma- 
tion may continue even where the original cause of the trouble 
(the gonococcus) is gone, "yet this is not the case so very often." 
A negative result, i. e., the inability to find the gonococcus, does 
not prove that no gonococci are present. Finger advises against 
marriage so long as pus cells are present. Kopp, in seven men 
with chronic gonorrhea, found no gonococci in the secretion after 
fifteen to twenty-two examinations, and yet these men infected 
their wives. Jullien, Wossidlo, Finger, and others report infec- 
tion of the wife in spite of the fact that repeated examinations 
showed no gonococci and in spite of the fact that cultures were 
negative. 



UNRECOGNIZED GONORRHEA IN THE FEMALE 

Readily as we diagnose gonorrhea in the male, just so poorly 
do we recognize gonorrhea in the female. The element which 
attracts attention in the male is the primary urethritis, accompanied 
by pain, burning, and discharge. From this come all the sub- 
sequent troubles. Through this urethral channel the various 
genito-urinary complications arise. In the female the urinary and 
genital organs have separate canals, and urinary and genital in- 
27 



418 MEDICAL GYNECOLOGY 

volvements by gonorrhea may occur independently or may be of 
different degrees of severity. An originally acute localized in- 
volvement in women often attracts little or no attention. A sub- 
acute invasion may, and frequently does, attract no attention at all. 

Urethritis. — An acute anterior urethritis in the female often 
causes such slight annoyances that the patient does not seek the 
services of a physician. Acute gonorrheal urethritis in the female 
has a tendency to heal without treatment in six to eight weeks. In 
other cases the discharge gradually becomes less, the symptoms im- 
prove, but a secretion persists, either because of a deep involvement 
of the mucosa of the urethra or because of an involvement of the 
urethral glands. Such a condition can be seen to develop after 
an acute gonorrheal urethritis. 

Many women come to us suffering from chronic urethritis with- 
out any evidence of genital lesions, though in many cases there is 
an associated cervical catarrh. Massage of the urethra, done 
several hours after the last urination, discloses a white, milky, 
mucoid discharge. The urethra may be sensitive and infiltrated. 
Examination of the discharge shows a few pus cells and a huge 
number of squamous cells of various shapes and sizes. Bacteria 
and cocci of different forms are often present, but very often no 
gonococci are found. There may be a history of relatively acute 
onset, the symptoms manifested at that time being frequency of 
urination and burning micturition. In some cases maculae gonor- 
rhoeae are present or there may be clear evidences of a cervical 
gonorrhea. The findings under the microscope in patients seen 
for the first time years after the beginning of their annoyance is 
exactly like that obtained in those acute cases which become 
chronic under our eyes. The same etiology is to be considered. 
The clearest cases are nulliparae in whom no pregnancy could 
have produced a septic involvement of the urethra, in whom there 
never was opportunity for the production of a catheterization 
cystitis, and in whom no fistulas are present. The absence of 
gonococci in the secretion and the presence of pyogenic cocci and 
bacterium coli is no reason for excluding an original gonorrheal 
etiology. 

I am of the opinion that the vast majority of such cases are due 
to a previously existing gonorrheal infection. 



GONORRHEA IN ADULTS 419 

Anal and Rectal Gonorrhea. — The unusual location of a 
gonorrhea may prevent its recognition at that particular point. 
Involvement of the anus and rectum by the gonococcus is by no 
means so rare in children and certainly not in adults. Baer found 
that, in one hundred and ninety-one cases of gonorrhea, there 
was rectal involvement in 30 per cent. There is a sensation of heat 
and burning, increased on defecation, and characterized especially 
by fissures. In four cases in children and in many cases in adults 
suffering from fissure of the anus, with pain on defecation, some- 
times accompanied by the presence of blood, I have been able to 
obtain smears in which the gonococci were readily found. I have 
been surprised to find this condition in several cases in adults who 
complained only of the rectal annoyance and who had not the slight- 
est subjective symptoms of a gonorrheal genital infection. That such 
a rectal and anal condition may exist without the finding of gono- 
cocci is to be expected, for a study of gonorrhea in other locations 
shows that eventually secretion is diminished or absent and the 
cocci disappear or cannot be found. In the majority of such cases 
we should find objective evidences of a cervico- uterine involvement. 

Gonorrheal Peritonitis. — Because the symptoms resemble 
other conditions, a gonorrheal etiology is often overlooked. A 
gonorrheal infection in children may spread upward into the 
uterus, up through the tubes, and involve the peritoneum with 
such rapidity that the vulvovaginitis has scarcely time to attract 
attention. In other instances the vulvovaginitis causes so few 
annoyances that little attention is paid to it. An involvement 
of the pelvic peritoneum and of the general peritoneum by 
the gonococcus is by no means unknown in children. It oc- 
curs with all the evidences of peritonitis and is sometimes very 
sharp in its onset, producing rigidity of the recti, temperature, 
pain, vomiting, and abdominal distention. In the absence of a 
recognized cause it is generally diagnosed as appendicitis, and 
frequently operation is performed for this indication. The rule 
should be formulated that every attack of peritonitis in female 
children which simulates appendicitis should have the gonorrheal 
possibility excluded. While operation is not followed by bad 
results, yet these cases improve on symptomatic and non-operative 
treatment. 



420 MEDICAL GYNECOLOGY 

The same point holds good in adults in those cases where there 
is rapid upward extension and infection, there being often no 
local symptoms whatever to call attention to the specific etiology. 
The symptoms are those of a peritonitis. In those instances in 
which adhesion of the tube does not occur quickly and in which 
the pus is poured out into the peritoneal cavity, and is accumulated 
in the cul-de-sac of Douglas, bimanual examination in patients 
with very tender abdomens and with rigid recti, may give no tangible 
evidence of involvement of the adnexa. The diagnosis may then 
be in doubt. In such cases, where a local specific infection is not 
thought of, the diagnosis of appendicitis is often made, and only 
operation discloses the real condition of affairs. In gonorrheal 
peritonitis the appendix is, as a rule, reddened, inflamed, and 
edematous, and if a small incision is made, the real condition may 
be overlooked. 

A frequent cause of failure to recognize the existence of gonorrhea 
is due to the mild nature of the infection. To most of us, if the 
first five days after labor are passed without a rise of temperature 
or pulse the probability of a post-partum infection of any sort is 
generally not feared. Yet there are cases where at the end of the 
first week, or more particularly at the second week, rises of tem- 
perature, not always high, are noted. Examination may show no 
marked parametritis, no involvement of the peritoneum, there 
may be no pain. Frequent and continued examination of the 
lochia will disclose in many of these patients the presence of the 
gonococcus. On the other hand, continued routine examination, 
persistently carried out, will often show the gonococcus to be 
present, even in post-partum cases, when no rise of temperature is 
noted (Kronig and Stone). 

Such involvement results in the so-called "one-child sterility" 
and in changes in the tubes. A parametritis, especially localized 
along the tube and near the ovary, and constituting a paraoopho- 
ritis or parasalpingitis, is very frequent and very frequently undis- 
covered. 

Gonorrhea is often unrecognized because the original char- 
acteristics have worn off in the course of time. 

Cyst of the Gland of Bartholin. — When an abscess involves 
the gland of Bartholin and calls for incision, very few doubt that 



GONORRHEA IN ADULTS 42 1 

the gonococcus is at fault. There are many instances of gonor- 
rheal infection of the gland of Bartholin in which no abscess re- 
sults. The duct is not closed and in the course of time the dis- 
charge becomes less purulent, finally becomes mucoid, and often 
of a normal color. If then atresia or obstruction of the duct 
occurs, a cyst of the gland of Bartholin results. While not generally 
so considered, there is no reason to doubt that many of these in- 
stances are to be referred to a gonorrheal infection of the gland, 
existing perhaps for years, and even to be referred back to the time 
of childhood. Therefore the resulting cyst contains an accumu- 
lation in which no gonococci are found and which seems under 
the microscope scarcely pathologic. 

Vulvovaginitis in Children. — The finding of purulent se- 
cretion and the absence of gonococci therein under the microscope 
does not exclude gonorrhea. Vulvovaginitis in children is at- 
tributed to various irritative causes, to various saprophytes and 
bacteria, and to the gonococcus. In children an acute vulvo- 
vaginitis with purulent discharge, in which the gonococci can be 
found, is by no means seldom. When the condition becomes less 
acute, although numerous pus cells are present in the discharge, 
gonococci are not so readily discovered. At a still later stage, 
when the pus cells are still fewer in number, it is a wearing task 
to find gonococci. In those long-continued chronic cases there is 
involvement of the cervix and of the uterus, and, as is also ob- 
served in adults, the microscopic finding of the gonococcus is 
by no means an easy procedure. The vaginal speculum in chil- 
dren shows a granular vaginitis and cervical erosion. Therefore 
these old chronic forms, as well as cases which are subacute and 
non-virulent from the beginning, are often considered, because of 
the absence of gonococcus findings, as due to other bacteria, whereas 
a large proportion of them are undoubtedly gonorrheal in eti- 
ology. 

The Diagnosis of Chronic Gonorrhea of the Cervix and 
Uterus. — In diagnosing chronic gonorrhea of cervix and uterus 
in adults we are dealing with greater obstacles than hamper the 
genito-urinary surgeons in making their microscopic determina- 
tions. It is rare that a gleet or a pathologic prostatic secretion or 
threads in the urine appeal to any one save as an evidence of a 



422 MEDICAL GYNECOLOGY 

previously existing posterior urethritis of gonorrheal nature. In 
women other bacteria are concerned in producing inflammatory 
involvements after labor, abortion, artificial abortion, etc. When 
looking for gonococci in the prostate one may use the so-called beer 
or coitus or silver tests, and by massage of the prostate may ob- 
tain a secretion showing gonococci. In women we are limited 
to frequent examination, especially after menstruation. The ad- 
visability of using intrauterine applications for increasing the se- 
cretion is a matter of dispute, but when done is of great aid. In 
women we find still greater difficulty, for the cervical mucus makes 
the discovery of gonococci by microscope or by culture difficult 
or impossible. Gonorrhea in the female may heal to all intents 
and purposes. Fluor is reduced to a minimum and no evidences 
are present in the external genitalia. In fact, in the vast ma- 
jority of cases no alterations are present in the external genitalia. 
A history such as is always present in the male is often absent. 
If in a chronic prostatitis gonococci cannot be found, and if the 
chronicity of the lesions is attributed to other associated bacteria 
or cocci, the disease is nevertheless gonorrheal in origin. The 
same is true in women, for when other bacteria and cocci come into 
the field the gonococci tend to disappear. We must parallel the 
experiences of genito-urinary surgeons and adopt the principle 
that the absence of gonococci in a pathologic cervical and uterine 
secretion, or even the absence of an evident secretion, by no means 
excludes the gonorrheal etiology of an active or passive, objective 
or subjective, alteration of an inflammatory nature. 

Use of the Microscope. — The use of the microscope has done 
much to hinder the diagnosis of old or subacute cases of gonorrhea 
in adults. A casual examination resulting in the discovery of no 
negative Gram diplococci has in innumerable instances excluded 
gonorrhea as the cause. In old cases the staining of several slides 
and several hours spent in their study are necessary to the finding 
of the much-sought-for cocci. When gonorrhea of the cervix and 
uterus becomes chronic, the discharge becomes less, and then mu- 
coid or mucopurulent and mixed with many squamous epithelia 
which may contain cocci. When this occurs, says Bumm, the 
prognosis is doubtful, for the cocci may disappear for weeks and 
then reappear. The only symptom is discharge, which is mucoid 



GONORRHEA IN ADULTS 423 

and often yellow or green; yet, according to Bumm, gonococci 
may be present even when the mucus is clear. 

Chronic gonorrhea of the cervix and uterus, according to Bumm, 
means the presence of mixed bacteria together with the gonococci, 
a fact which still further confuses an attempt at diagnosis by mi- 
croscope or culture. 

Clinical Diagnosis of Latent Gonorrhea. — Are we in a 
position to clinically diagnose chronic gonorrhea when few pus 
cells and no gonococci are found ? I believe that certain cervical 
alterations are of importance in this connection, especially when 
a chronic urethritis is not present, when maculae gonorrhceicae or 
other external evidences are absolutely absent, and when tubal and 
peritoneal changes are not marked. 

Erosions oj the Cervix. — This is a condition which is ex- 
tremely frequent and is generally noted in nulliparae suffering from 
cervical or uterine catarrh. It is due to the maceration and de- 
struction of the squamous epithelium about the external os and its 
replacement by the cylindric epithelium which normally lines 
the cervix. When this condition exists in nulliparous women who 
have not been curetted, or in whom other means of infection are 
to be excluded, a gonorrheal infection must be considered. (For 
me, after close observation, the axiom has been adopted that cer- 
vical erosions plus a pathologic cervico-uterine discharge in nulli- 
parae are presumptive evidence of cervico-uterine gonorrhea.) 
In addition to erosions, there is a characteristic cervical catarrh. 
The cervix is dilated, there is an extremely thick plug of mucus 
rilling the cervix and protruding from the external os. Its color is 
white and yellow. With it there is a reddened external os, if 
erosions are not present. Examination of the secretion shows 
mucus, squamous epithelia, and many leukocytes. Pure pus in 
this cervical type is not found. The mucus has a destructive action 
on all the cells which are taken up in its structure, and their form 
is changed. Bacteria are almost never found in the mucus. For 
that reason gonococci, unless the cervical wall is scraped or unless 
the uterus is involved, are almost never found. This condition is 
seen to develop in patients who have been treated for acute cer- 
vical gonorrhea, and is most frequent in those cases in whom the 
main activity of the gonococci seems to be limited to the cervix. 



424 MEDICAL GYNECOLOGY 

When existing in nulliparae and when present to a marked degree 
in uniparae, it is for me extremely suggestive of the existence of a 
cervical gonorrhea, even if no erosions are present and even if no 
involvement of the adnexa can be made out. I base this opinion 
upon the fact that many such patients have salpingitis and oophor- 
itis and on the finding in one-third of the cases of gonococci after 
prolonged examination. 

Parametritis posterior is a very frequent condition. This 
is a lesion which occurs in nulliparae, and especially in women who 
have borne one or more children. In the latter it often produces 
symptoms shortly after childbirth, but may give no symptoms 
then. It consists of a slowly progressive chronic infiltration of the 
uterosacral ligaments and the pelvic connective tissue surround- 
ing the posterior fornix. The parturient cases have only slight 
or no temperature reactions, suffer from pain in the back, con- 
valesce slowly. Bimanual examination shows an exceedingly 
tender, edematous, or infiltrated posterior parametrium. There 
is also present a reddened external os and slight or large amounts 
of cervical discharge. Careful early examination in these early 
cases often discloses the gonococcus. In other cases the gono- 
coccus cannot be found, but the parallel with other instances 
makes this etiology extremely probable. When this condition con- 
tinues, there results a sclerosis of the uterosacral ligaments on one 
side or on both sides. Associated with it is a chronic cervical 
catarrh, though the latter in the course of time may so improve as 
to give only minimal evidences. This condition is by no means in- 
frequent in nulliparae suffering from chronic cervical catarrh, in 
whom no other factor but the gonococcus can be referred to as the 
cause. Its presence in nulliparae in conjunction with erosions, red 
external os, and pathologic cervical discharge means, for me, the 
diagnosis of gonorrhea. A frequent location of the parametritis 
is along the course of the tubes and near the ovary. It is responsi- 
ble in many cases for an acquired ovarian dysmenorrhea with 
varicocele of the broad ligaments. 

Use of the Curet.— Those who have observed the tendency to 
the indiscriminate use of the curet for the cure of primary sterility 
and for the cure of uterine catarrh have noted that in many cases 
the cervico-uterine catarrh did not improve, that in some cases it 



GONORRHEA IN ADULTS 425 

was made distinctly worse, and that in many cases the result of 
dilatation of the cervix and of the curettage was pelvic pain and 
temperature. Examination discloses an involvement of the para- 
metrium on one side or the other, or an inflammatory involvement 
of the uterine adnexa of one side or both sides. In fact, a large 
proportion of cases of sterility associated with pain which I have had 
the privilege of observing are such patients as have been curetted 
for primary sterility. Infection of the usual septic character can 
often be excluded, and we are forced to the conclusion that dilata- 
tion of the cervix and curettage often set into more active being the 
slumbering cocci of a non- recognized gonorrheal catarrh of the 
cervix and uterus. 

There is found in many women suffering from sterility, and 
especially in such as have been curetted for sterility, a mild one- 
sided or double-sided salpingo-oophoritis, associated with pain in 
the region of the ovaries. In these cases there may exist erosions 
or cervical catarrh, or these conditions may not be marked. If 
tuberculosis can be excluded and if a previous appendicitis has not 
existed, the cause, in the vast majority of instances in nulliparae, 
is to be referred to a mild gonorrhea. On operation those cases 
not infrequently show closure of the tubal ends or cobweb adhesions 
around the tube and ovary which to all intents and purposes 
close the ends of the tubes. This condition is frequently one- 
sided, and after abdominal operation, and more frequently if a 
curetting be combined with the operation, an extension to the 
other side in the course of time is noted. In this condition there 
is not infrequently found small cystic degeneration of the ovaries. 
Particularly in those cases in which the ovary contains one large cyst 
the size of a walnut, and in which the broad ligament veins consti- 
tute a varicocele, the probabilities are that we are dealing with an 
infection of a ruptured Graafian follicle which, after its closure, 
becomes distended by the accumulation of secretion within it. 

Sterility in very many cases is to be referred to lesions of the 
tubes. Given a sterile woman with well- developed uterus and 
ovaries (if the spermatic fluid is found normal), and, if stenosis of 
the cervix and the internal os can be excluded by treatment or 
operation, the cause of the sterility must be referred to the tubes. 
Such cases are frequently found after curetting. We may safely 
take it for granted that there exists a mild inflammatory involve- 



.426 MEDICAL GYNECOLOGY 

ment of the Fallopian tubes, perhaps only affecting that part close 
to the uterus, but quite sufficient to destroy the activity of the 
ciliated epithelium. As a result the ovum cannot enter the uterus 
and sterility is the consequence. In this way can be explained many 
cases of pregnancy occurring years after marriage, especially in 
those cases where treatment was finally given up and several years 
have elapsed, during which time the natural resistance of the pa- 
tients has restored the tubes to a normal condition. 

Ectopic Gestation. — The cause of ectopic gestation is to be 
referred, in the majority of cases, to some obstruction in the inner 
lining of the tube. There is either a mild fresh salpingitis or there 
is an old, nearly cured salpingitis. The ciliated epithelium in 
the outer end of the tube is not yet involved or else has been 
restored to normal activity, but beyond that the tube is either 
obstructed by adhesions of tubal mucosa or by an edematous mu- 
cosa or else the ciliated epithelium is not functioning. The find- 
ing of cilia in sections of the inner area of the tube has been very 
extensively used as a refutation of this causation. It may be 
said that finding cilia is no proof of their activity, for even in pyo- 
salpinx in certain areas the ciliated epithelium is to be found. 
Therefore, an ovum given off from the ovary, if fecundated, passes 
along the tube up to the point where there is an obstruction or 
where ciliated epithelium no longer functionates, rests there, con- 
tinues its growth, and ectopic gestation results. The occurrence 
of ectopic gestation after long periods of non-artificial sterility, 
the occurrence of repeated ectopic gestation, the frequent finding 
of adhesions or scars in the tube, and the by no means rare inflam- 
matory involvement of the opposite tube speak for such a tubal 
alteration in many cases. In many cases in which at operation I 
paid particular attention to the opposite tube, there was found a 
closed outer end. Adhesions were present about that tube and 
ovary, i. e., alterations of such a character as to warrant removal. 
That gonorrheal infection is the cause in a goodly proportion of 
cases is my opinion. 

Course of Mild Gonorrhea. — The main reasons why the con- 
ditions to which I have referred constitute unrecognized forms of 
gonorrhea are two: Either the original gonorrheal infection was 
so situated as to cause bearable annoyance, as is often the case 
with gonorrhea of the urethra, and involvement of the cervix if 



GONORRHEA IN ADULTS 427 

both remain localized, or the situation is unusual and occurs with 
symptoms resembling other diseases, or else the original infection 
was of so mild a character as never to attract the attention of the 
patient at the time. Such is the history of the vast majority of 
infections which take place in the female. They are the result of 
old, chronic, supposedly cured or supposedly harmless involve- 
ments of the prostate or seminal vesicles. Such gonococci have a 
tendency to form superficial involvement, and there is nothing in 
the character of the infection to attract notice. In these mild 
cases the urethra is rarely involved, for the simple reason that the 
infecting cocci are mixed with the seminal and prostatic secretion 
and are deposited in the vault of the vagina. There results finally 
a cervical catarrh. Extension is favored by rough intracervical 
manipulation, by curettage, by operation, by labor, and by abor- 
tion. In an acute gonorrheal involvement it is not easy after a 
certain period to find the gonococci extracellular or intracellular. 
In these milder cases it is extremely difficult to find them because 
of the mucoid character of the cervical discharge and because the 
cocci in the depths of the glands are not cast off in slumbering 
cases without stimulation or irritation. Were such conditions to 
be found in multiparas alone, it would be difficult to form a defi- 
nite opinion. Even here, the fact that a woman has borne several 
children does not exclude the existence of a cervical infection. 
Many women with a cervical gonorrhea which remains localized 
go through successive pregnancies. It is probable that an in- 
volvement of this mild nature which does not, post partum, ex- 
tend upward and involve the uterus, tubes, and peritoneum after 
the first labor, and which therefore permits of a second pregnancy, 
will, in all probability, never extend further than the cervical 
lining, and if it does so its course will be mild. When gonorrhea of 
the cervix and uterus becomes chronic, the discharge becomes less, 
and then mucoid or mucopurulent and mixed with many squamous 
epithelia which may contain cocci. When this occurs, says Bumm, 
the prognosis is doubtful, for the cocci may disappear for weeks 
and then reappear. The only symptom is discharge, which is 
mucoid and often yellow or green. The milder lesions referred to, 
and which affect the cervix, the posterior parametrium, the uterus, 
the peritoneum, and the ovary, are frequently found in women who 
have borne one child, but most frequently in women who are sterile. 



428 MEDICAL GYNECOLOGY 

In the majority of such cases no other etiology than gonorrhea 
can be found. No etiology can be considered, except a mild in- 
fection from below by the gonococcus from a dormant male pros- 
tatitis. I have come to this conclusion from a study of cases 
acutely infected by the gonococcus and in whom the gonococcus 
was clearly demonstrated. In the course of months and years the 
original typical character of the inflammation changes to a type 
so often found on the first examination of long- suffering patients. 
Therefore, when such cases, particularly nulliparae, are seen for 
the first time, and present the typical picture of erosions, of cer- 
vical catarrh, uterine catarrh, salpingitis, mild salpingo-oophori- 
tis, mild tubal adhesions, and sterility, and if primary intraperi- 
toneal causes can be excluded, the only conclusion to be reached is 
that we are dealing with subacute infection, probably by a non- 
virulent type of gonococcus. Examination of the husband will dis- 
close a prostatitis or show threads in the urine or divulge the history 
of a new infection after marriage. 

Virulence of the GonococcL — Many observers will not grant 
that there is a difference in the virulence of gonococci. They say 
that when transplanted to new soil, any gonococci may cause acute 
infection in favorable soil. Mild attacks, they say, are due to the 
resistance of individuals or to the element of localization. 

Bumm says that the severity of the infection depends on the 
localization, that gonorrhea is light if located in the cervix or urethra, 
and severe if it extends upward quickly. Bumm says that it is 
often isolated in the cervix, while Wertheim says that it is in the 
uterus much more often than we realize. 

On the analogy with other bacteria we have the right to predi- 
cate various degrees of virulence in different gonococci. It is 
natural to expect that gonococci few in number and found with 
difficulty in the male prostate years after the original infection may 
cause a less acute involvement of the cervix than the cocci from a 
fresh or recent gonorrhea in the male. While I have no warrant 
for this statement on the basis of experimental proof, I may quote 
the opinion of Doderlein that acute gonorrhea in the female comes 
from acute gonorrhea in the male, and that subacute gonorrhea comes 
from a chronic subacute disease in the male. The subacute form 
has none of the symptoms of the acute form, often presenting only a 
discharge. With this statement I agree on the basis of clinical facts. 



GENITAL SYPHILIS. 

Hard chancre is an ulcer developing two to three weeks after 
infection by the spirochaete pallidum. It is not deep, but flat and 
plate-like in form, sometimes elevated. The base is smooth and 
shining; the secretion is slight, not purulent but serous. 

In women the induration and hardness which are considered 
to be characteristic of this primary lesion of syphilis are not so 
frequently noted as in men, and if present they last but a short 
while. In fact, this primary lesion is rather difficult to find in 
women, and it often escapes observation. 

Usually there is only an erosion of the mucous membrane which 
represents nothing characteristic, and which may easily be mistaken 
for a vesicle or harmless lesion. It looks so benign and superficial 
that the diagnosis is not easy. This small erosion is the more 
readily overlooked if, as often happens, some inflammatory process 
associated with secretion is present in the vulva or vagina. The 
course of this specific erosion is a short one, and generally no sign 
is left after fourteen days. 

If this erosion is present on the labium ma jus, there is then a 
marked cartilaginous induration whereby the ulcer is elevated. On 
the labium minus the hardness is more like that of parchment, and 
in the vestibule and vagina it is rarely observed. Here there is 
generally a sharply outlined erosion of the color of muscle tissue. 

Sometimes chancre begins, as in men, as a nodule. This is 
especially so on the outer surface of the labium majus and on the 
prepuce of the clitoris. Sometimes such nodules develop about a 
hair-follicle. They ulcerate, and then two or three may be present. 
These ulcers are sharply outlined and take a long time to heal. 

A condition which often accompanies chancre on the large or 
small labia is known as oedema indurativum. Without any evi- 
dence of inflammation there occurs a more or less marked swelling, 
which is firm and does not pit on pressure. It develops slowly and 
without pain, and the edema may spread to the clitoris and mons 
veneris. 

429 



430 MEDICAL GYNECOLOGY 

In the vagina chancre is very rarely observed. It occurs in this 
location as primary lesion in one case out of two hundred. When 
it does occur here, it heals in two weeks and causes no symptoms 
of local annoyance. 

The vaginal portion of the cervix is the site of chancre in perhaps 
15 per cent, of the cases, according to Joseph. It is most common 
about the external os, in the edges of the cervical lips, which are 
rich in glands, and in the lowest third of the vaginal portion. It 
extends generally over both lips, with the anterior lip usually more 
involved. It may be single or multiple, round or oval, and of a 
gray or gray-white color. It heals within two or three weeks, 
generally without evidence, but sometimes with scar formation. 
It occurs most frequently in women who have borne children, 
since the virus enters more readily into the easily injured tissue. 

This ulcer of the portio, in the beginning, is hard to differentiate 
from other processes. Later on it is indurated, sharply outlined, 
and covered with diphtheritic light membrane. The superficial 
form resembles an erosion, while the deeper ulcerated form has 
sharply cut edges. The following dusting-powders are used for 
the primary lesion : 

1^. Calomel 5 ss 

S. — As dusting-powder. 

1^. Europhen 5 j 

Acidi boric 5ij 

S. — As dusting-powder. 

1$. Xeroform 5ij 

S. — As dusting-powder. 

Lymphadenitis Syphiliticum. — This develops a few days 
after the primary lesion, or about three or four weeks after the 
infection. If induration is associated with the primary lesion 
this involvement usually takes place concurrently with it. The 
glands nearest the primary lesion swell to the size of a walnut and 
are movable. Several glands are generally involved and are charac- 
terized by a chronic painless growth without inflammatory evidence 
or redness or temperature, and therefore are called indolent bubo. 
Two or three weeks later than the glands situated near the pri- 
mary lesion, the more distant glands are involved, and six or eight 
weeks after infection the lymph-glands of the body are involved, the 
so-called lymphadenitis universalis. 



SYPHILIS 431 

Generally the inguinal glands are first involved, then the iliac, 
then the axillary, etc. 

This chronic indolent lymph-gland swelling is a characteristic and 
pathognomonic symptom, which justifies the diagnosis of syphilis. 

1$. Ung. hydr § ss 

S. — Rub in, daily, a piece the size of a pea over the glands. 

Ulcus durum, the primary syphilitic lesion (Joseph), is the 
first sign of syphilitic infection; from this lesion the neighboring 
lymph-glands and lymph-vessels are involved. Later the distant 
glands are affected. Gradually the entire organism is involved 
by the syphilitic virus, and as a rule in six to twelve weeks the 
skin shows typical evidences of this general infection. 

Between the occurrence of the primary lesion and the appearance 
of the syphilitic general evidences — that is, during the second incu- 
bation period — the body shows a series of subjective and objective 
symptoms known as the prodromal symptoms, just as is noted 
with other infectious diseases. Anemia is a symptom, especially 
in women. Temperature is noted, generally just before the ap- 
pearance of the skin eruption. There are frequently nervous 
symptoms, such as melancholic depression, headache, neuralgia, 
and the reflexes are increased. The spleen is enlarged and there 
is pain in the bones and muscles. 

When the specific process affects the skin, evidence is complete 
that the disease has become constitutional (second stage). This 
early involvement takes the form of copper-brown, polymorphous, 
slowly developing, diffusely distributed, chronic, recurring syphil- 
ides, most frequently in the form of roseola or erythema syphili- 
ticum, small papular and large papular syphilides. 

The diagnosis of syphilis is absolutely certain so soon as typical 
evidences of cutaneous syphilis appear. Of the syphilides, large 
nodular or papular syphilides, when macerated, become moist 
papules. These when situated on a mucous membrane are known 
as mucous patches or plaques. These moist papules may be situated 
on the vulva, the large or small labia, the perineum, the inner surface 
of the thighs, and about the anus. The moist papules situated in 
these regions are known as condylomata lata. 

Condyloma latum represents a very red, button-like, warty 
overgrowth of small or large size, which arises through increased 



43 2 MEDICAL GYNECOLOGY 

growth of individual papules or through the union of some of these 
into large plaques or masses. They have a smooth or papillary 
surface and are of elastic consistency, but external irritation may 
cause the surface to take on a cockscomb-like growth, due to de- 
velopment of the papillary bodies, as in pointed condylomata. 

Broad condylomata are generally covered by a gray-white 
membrane, but if kept dry, they change to simple dry papules. 
Usually the skin areas are involved in a symmetric manner. Es- 
pecially is this so on a mucous membrane or about the anus. This 
is due to inoculation by the secretion from these moist papules, 
especially if associated with an irritation. If the usual superficial 
destruction extends more deeply into the papillary bodies, we then 
have a condylomatous ulcer. Sometimes a primary lesion changes 
to a condyloma latum, or a condyloma latum, through infiltration 
of the base, may take on the appearance of a primary ulcer. 
Condyloma latum generally occurs in the first years after infection, 
rarely later. This form of eruption may recur often. The puru- 
lent, foul secretion of condylomata lata is very infectious. They 
heal well unless condylomatous ulcers are formed, and then these 
leave scars. They heal well when powdered with calomel or 
covered with mercury plaster. Condylomata lata on the cervix 
are rare. For condylomata lata : 

1$. Calomel §ss 

S. — As dusting-powder. 

1$. Mercury plaster — emplastrum hydrarg. 
S. — Cover daily with a piece. 

For mucous patches : 

T$. Hydrarg. chlorid. corrosiv gr. iss 

y£ther sulphur §iss 

Spiriti rectificat §iij 

S. — Cauterize daily with this solution. 

Or— 

~Rf,. Sol. acidi chromici (io per cent.) Sj 

S. — Cauterize daily with this solution. 

Gummata occur mostly in the skin, but may be found in any 
organ of the body. While the other eruptive forms come early in 
the disease, gummata first appear one or two years or more after the 
infection (in the third stage). Gummata are contagious and con- 
tain the spirochete pallidum. 

The urethra is seldom involved. When affected, it takes the 



syphilis 433 

form of diffuse gummatous infiltration of the walls or of ulcers 
of the size of a pea or walnut. The ulcer formation is often called 
ulcus rodens urethrae or ulcus diphtheriticum, which runs a very 
chronic and stubborn course. It begins as a little ulcer about the 
urethra, with deep brown, red, shining, smooth base, covered with 
a grayish- yellow membrane, with sharply outlined edges. It 
heals under energetic antisyphilitic therapy. It causes few sub- 
jective symptoms and often recurs. 

Gumma of the vulva begins years after the primary lesion as a 
painless infiltration of the labium majus. After the infiltration 
extends to the urethra urination is painful. It generally extends 
to the perineum, and causes pain on defecation, and the stools 
contain blood. Rarely are both labia affected symmetrically. 
After degeneration of the gumma, we have a crater- like ulceration 
with irregular edges, spreading in serpiginous form and extending 
to the vagina. The diagnosis is difficult because the primary 
lesion was probably never noted and because the early symptoms 
of constitutional syphilis may not have appeared or may not have 
been noted. Joseph states that most of the cases called esthyo- 
mene or elephantiasis of the vulva are gumma ta. 

Gumma of the vagina is very rare and is mistaken for carcinoma. 
In doubtful cases a syphilitic cure should be tried. It takes the 
form of an elliptic ulcer, sharply outlined, more or less deep, covered 
with a yellow secretion, and having a spongy, readily bleeding, granu- 
lated base. It is generally situated near the ostium of the vagina. 

Treatment of Syphilis (Max Joseph). — The ideal treatment 
of chancre when localized, and when the period is sufficiently 
early to be favorable, is excision. The ulcer is lifted up with a pair 
of forceps and cut off with one clip of the scissors into the healthy 
tissue, and the wound closed with sutures. If the primary lesion 
is but little developed, and if indolent lymph- gland swellings 
cannot be felt, and if the spirochete pallida are found, excision 
should be done. If no general symptoms occur, a subsequent 
course of treatment is not attempted by some until roseola appears. 

Excision brings about a rapid local healing within a week, which 
is a great saving of time as compared with the ordinary treatment 
of chancre, which lasts quite a period. It certainly diminishes 
the amount of virus absorbed into the system and the regional 



434 MEDICAL GYNECOLOGY 

lymph-gland swelling does not take place. If the original excision 
is not made into healthy tissue or is made late, the scar may become 
indurated or may break open into a typical chancre. When seen 
at the stage of typical chancre with induration and regional 
lymph-gland swellings, these glands may also be extirpated, with 
probable benefit to the patient, but this implies quite an operation. 
All this diminishes the virulence of the subsequent general infec- 
tion. It, however, may only put off the occurrence of the general 
symptoms, which have been known to appear as long as six months 
to even two years after the primary excision. 

Treatment. — The diagnosis having been made by finding the 
spirochete or by waiting for the skin eruption, the first course of 
treatment should be one by inunction, 45 grains of unguentum 
hydrargyri being rubbed in daily on the various hairless parts 
of the body for a period of twenty to thirty minutes. In stubborn 
cases twice as much unguentum hydrargyri is used. Those 
parts of the body which are free from hair are selected. These 
rubbings should be repeated for four days. On the fifth day the 
rubbing should be done on the back for half an hour by a masseuse. 
The best hour for these inunctions is before retiring. On the 
sixth day a bath should be taken. This procedure is repeated 
until the patient has taken thirty rubs. The mercury is absorbed 
partly through the skin and partly through the lungs, the mercury 
evaporating from the skin. Hence some use mercury rubbed 
into flannel and fastened about the neck and abdomen like an 
undershirt and worn day and night. Seventy-five grains are rubbed 
in every two or three days. 

The use of unguentum hydrargyri may cause folliculitis: that 
is, pustules around the hair-follicles. If so, the rubbing with 
unguentum hydrargyri should be stopped for a few days, and in 
its place the affected area should be rubbed with : 

1^. Zinci oxidi o ss 

Amyli 5ss 

Vaselini flavi 5 j 

In place of the unguentum hydrargyri there may be used 
unguentum hydrargyri cinereum cum resorbin. parat. 33J per 
cent, (resorbin-mercury ^\ per cent.), rubbed in from ten minutes 
to one-half hour. 



SYPHILIS 435 

After this inunction cure there should be a rest of several weeks, 
which may be well spent at the seashore or in the mountains. 
Then during the latent stage, unguentum hydrargyri, the size of a 
pea, is rubbed daily into the inguinal glands and the glands of 
other parts of the body. This is stopped when no more enlarged 
glands are to be found anywhere. 

If no symptoms such as condylomata lata or mucous patches 
appear during the next few months, the patient should be let 
alone; but if these conditions do come on, they should be treated 
locally. If in spite of local treatment there is no improvement, 
internal treatment should be used. 

1$. Hydrarg. chloridi corrosivi gr. ij 

Boli albae praep 3 j 

Glycerini q. s. u. f. pil. no. xl. 
S — One t. i. d. p. c. 

Or— 

1$. Hydrarg. tannici oxydulat gr. xx 

Boli albae praep 5 j 

Glycerini q. s. u. f. pil. no. xl. 

S. — Two p. c. (Lustgarten). 

The inunction cure is to be repeated six months after the first 
one, even if no symptoms recur or present themselves. 

In place of inunctions we may give injections, 15 minims a day, 
into the muscle of the nates, of: 

1$. Hydrarg. chloridi corrosivi gr. v 

Sodi chloridi gr. xlv 

Aqua dest. ad § j 

Thirty such injections are given. In place of the above, in order 
to spare the patient the annoyance of coming too frequently we 
may use: 

1$. Hydrarg. chloridi corrosivi gr. x 

Sodii chloridi gr. xlv 

Aqua dest. ad O j 

Give 15 minims once a week by needle for four to twelve weeks. 
We may inject calomel, or we may inject: 

~fy. Hydrarg. salicylici gr. xlv 

Parafhni liquidi ad § j 

Or hydrargyrum salicylicum in vasenol (10 per cent.), which is sold 
in sterile glass tubules. Inject 7 minims into the muscle. In four 
days repeat this; in four days more inject twice the amount, and 
then every eight days until eight injections have been given in all. 
During the entire cure the teeth must be carefully cleansed 



436 MEDICAL GYNECOLOGY 

three times daily, and every hour the mouth must be washed with 
half a teaspoonful of liq. aluminii acetatis to the glass of water, 
or with 2 per cent, peroxid. There should then be a rest of a few 
weeks and recurrences should be treated by local medication. 

Six months after the second cure comes the third cure, either by 
inunction or injection, plus the use of iodid of potash, of which 
600 to 750 grains are taken in doses of 10 grains t. i. d. 

When six more months have passed, the last cure by inunction 
is taken, 45 grains of unguentum hydrargyri being rubbed in daily 
for thirty days. 

At the end of this cure two years have passed since the infection. 
After a few months of recuperation a total of 600 to 750 grains of 
iodid of potash are again taken. 

In the interval between all the cures enlarged lymph-glands are 
treated locally by mercury ointment. 

If two years have elapsed after the last cure without recurrences, 
the patient may marry, if first another energetic inunction cure is 
taken (Max Joseph). 

For the differential diagnosis between hard chancre and soft 
chancre, see page 438. 



ULCUS MOLLE (SOFT CHANCRE OR CHANCROID) 

A few hours after infection by the soft chancre of another indi- 
vidual a. redness occurs at the point of inoculation. After twenty- 
four hours, sometimes after two or three days, there occurs a pustule 
which breaks on the second or third day, rarely as late as the 
fifth. The resulting ulcer is round, deep, as if bored out, and 
has flabby but sharp, somewhat undermined elevated edges. The 
base is uneven and covered with a grayish-white, dirty, firmly 
attached covering. The ulcer bleeds easily, and secretes a very 
contagious pus. 

Soft chancre is caused by the strepto-bacilli described by Ducrey 
and others. It is diagnosed not only from its appearance, but 
from its clinical course, for soft chancre is always a local disease. 

Soft chancre is an ulcer which takes a slow course. The ulcer 
does not enlarge greatly and reaches the size of a five-cent piece. 
In the first three or four weeks the purulent discharge is very 



syphilis 437 

infectious, and by inoculation new ulcers are formed about the 
original one. 

As a rule, with soft chancre, there are several ulcers present. 
In the fourth week the redness and swelling diminish, the pus 
becomes less in amount and is no longer infectious. Marked 
granulation is evident in the base of the ulcer, which may rise above 
the surface, forming the ulcus elevatum. If let alone, it heals in 
five to eight weeks, leaving a soft scar. In weak individuals the 
ulcer may take on a gangrenous character or may have a diphtheritic 
appearance, which forms are rare in women. 

Soft chancre occurs mostly on the fossa navicularis, about the 
external opening of the urethra, or on the clitoris, is often situated 
on the large labia or on the inner surface of the large or small labia, 
rarely on the mons veneris, more often about the anus. 

Soft chancre rarely occurs in the vagina or on the vaginal por- 
tion of the cervix. In this latter situation it represents a sharply 
edged, easily bleeding ulcer, with thick pus covering it. It spreads 
rapidly and heals after two to five weeks with the formation of a 
scar. Generally other ulcers are present on the external genitalia. 

In the early stages it should be excised; in the later stages it 
should be treated with pure carbolic acid or tincture of iodin, 
followed by the regular use of iodoform, etc., as follows: 

1$. Ol. sassafras gtt. ij 

Iodoform ad 5 iiss 

S. — As dusting-powder. 

Bf. Europhen 5j 

Acid, borici 5 iij 

S. — As dusting-powder. 

For condyloma acuminata may develop in the fossa navicularis, 
on the perineum, in the labio-crural folds, or in the vagina even up 
to the cervix ; 

1$. Resorcin 3 iiss 

S. — Ext. as dusting-powder. 

J$. Liq. potassii arsenitis 5 iiss 

Aq. destillat 5 iiss 

S. — Applied with compresses to the condylomata several times a day. 

Inguinal bubo forms in one-third of the cases. Generally in 
the first or second week pain is felt in the inguinal region. There 
is a slight rise in temperature. First one gland swells, and then 



438 



MEDICAL GYNECOLOGY 



others. The glands and the periglandular tissue are involved. 
The periphery becomes edematous and so is the skin over the 
glands. Suppuration develops in parts, forming small abscesses 
which grow larger and finally unite. The treatment is then sur- 
gical. 

1$. Hydrarg. benzoici. 

Sod. chlorid aa. gr. xv 

Aq. dest. ad g iij 

Inject 2 to 3 c.c. into the glands at intervals of a week as abortive treat- 
ment (Welander). 



DIFFERENTIAL DIAGNOSIS BETWEEN CHANCRE AND SOFT CHAN- 
CRE OR CHANCROID, ACCORDING TO JOSEPH 



Chancre 
Long period of incubation, generally 
two to three weeks. 



2. Generally single. 

3. Flat or elevated ulcer. 

4. Only a weak line of delimitation. 

5. Smooth shining base. 

6. Slight serous secretion. 

7. Often a hard cartilaginous base. 

8. Indolent non-inflammatory bubo 

occurs shortly after the primary 
lesion. 

9. Secretion is infectious to the patient 

only for a few days in the begin- 
ning. 

10. The spirochete pallida are present. 

11. Generally heals without a scar. 

12. Calomel powdered on the ulcer 

morning and night brings about 
healing. If it heals slowly, dust 
it with iodoform or europhen or 
zeroform. In place of calomel, 
mercury plaster may be put on 
and changed every twenty-four 
hours. 



Chancroid 

1. Short period of incubation. After 

twenty -four hours there is a 
pustule; after three days there is 
an ulcer. 

2. Generally multiple. 

3. Deep, punched-out ulcer. 

4. Steep, undermined edges. 

5. Uneven, punched base. 

6. Plentiful purulent secretion. 

7. Soft base; slight hardness in iso- 

lated spots. 

8. No swelling of the glands, or else 

there is a virulent bubo with in- 
flammatory evidences. 

9. Pus can be inoculated upon the 

patient and causes a new soft 
chancre. 

to. Strepto-bacilli are the cause. 

[i. Heals with a deep scar. 

[2. In the early stages it should be 
excised. In the later stages it 
should be treated with pure car- 
bolic acid or tincture of iodin, 
followed by dressing with iodo- 
form. 



VULVITIS 

Furunculosis vulvae is a condition not infrequently met with, 
especially in older women. A furuncle appears as a small, hard, 
nodular swelling, which is red and painful. It becomes larger, 
sometimes extending superficially and forming a pus-nodule; at 
other times spreading deeply and producing a phlegmon, with 
quite extensive infiltration of the connective tissue of the large 
labium. New nodules form as the old ones heal or are treated, 
and the condition may spread or extend and last for weeks. It 
is often one-sided. 

The Treatment oj Furunculosis. — Small unripe furuncles should 
be touched with pure carbolic acid and then thoroughly painted 
with several coats of iodin. This may prevent their further exten- 
sion and development. If a furuncle goes on to the formation of 
purulent accumulation, it should be incised and touched with 
either pure carbolic acid followed by iodin or with a 40 per cent, 
solution of carbolic acid in alcohol. When furuncles, instead of 
developing superficially, extend deeply into the connective tissue 
and form a phlegmon, abortive treatment is advisable. Very hot 
sitz-baths of a duration of twenty minutes should be taken. Moist 
applications of gauze, saturated in a strong hot solution of acetate 
of aluminum, should be applied constantly and constantly changed. 
If this treatment does not suffice to prevent the extension or the 
breaking down of the phlegmon, incision and surgical treatment 
are necessary. To prevent the continued extension and continua- 
tion of this condition, internal medication should be tried in the 
form of calx sulphurata or compound syrup of hypophosphites. 
The urine should always be examined for sugar. 

Vulvitis. — The term vulvitis is applied to affections of the skin, 
of the mucous membrane, or of the glands of the vulva. The term 
vulvitis is often used to describe conditions involving simply the 
skin area of the vulva, which strictly do not constitute a vulvitis, 
but belong rather to the category of pruritus vulvas. Lack of 

439 



440 MEDICAL GYNECOLOGY 

cleanliness, especially in older women with lacerated perinea, 
with resulting mild vaginitis, may involve the skin area of the 
vulva. Like causes produce skin irritation, such as intertrigo, 
which occurs in fat persons, especially in the summer-time. There 
is, in addition, a dermatitis which may spread from the inner sur- 
face of the thighs and involves the vulva. It occurs often in fat 
persons. Such conditions, due to un cleanliness, to contact of the 
parts, etc., are accentuated by scratching. There may also be 
conditions of the same character as affect the skin in other parts 
of the body, such as acne or herpes, eczema, various parasitic 
conditions. Herpes vulvae is especially observed in pregnant 
and fat women. It is characterized by groups of small vesicles 
whose appearance is preceded by pain. They generally disappear 
in the course of a week or ten days. 

Onanie as a Cause of Vulvitis. — There may be a lengthening 
of the small labia and the clitoris, a condition to which Dickinson 
has called attention, but this is not always present. The sebaceous 
glands on the inner surface of the small labia and on the vestibule 
are increased in size, so that the inner surface becomes uneven and 
looks as if it were covered with file-like elevations. There is often 
an increased discharge of mucus from the glands of Bartholin, 
and huge amounts from the cervix. At times the vulva has a very 
red, congested look. 

An acute inflammatory vulvitis, really constituting a vulvo- 
vaginitis, occurs in children as a diphtheritic inflammation in 
diphtheria, and more frequently as an eruptive, ulcerative, or 
necrotic condition in the infectious diseases of children, such as 
scarlatina, measles, etc. A gonorrheal vulvitis in children is by 
no means infrequent, producing, in addition to burning and itch- 
ing, few annoying symptoms. It is only part of a gonorrheal vulvo- 
vaginitis. A real vulvitis occurs in adults as a result of, or in com- 
bination with, inflammations of the urethra, of the vagina, of the 
cervix, usually gonorrheal. In addition, the vulva may undergo 
marked chemical or bacterial irritation from the secretions of a 
degenerating or necrotic carcinoma or myoma of the cervix or 
uterus, or from the urine associated with a cystitis or discharged 
from a fistula. 

A catarrhal vulvitis is an inflammatorv affection of the mucous 



vulvitis 44 r 

membrane on the inner surface of the labia majora and the labia 
minora, on the clitoris, and in the vestibule up to the hymen. 
With it are often combined inflammations of the urethra, of the 
ducts of Bartholin, of Skene's glands, i. e., of the mucous membrane 
canals which open into the vestibule. In acute infectious cases 
the diagnosis is made by inspection. The labia majora and minora 
are swollen. Touching the parts causes contraction of the constric- 
tor cunni or vaginismus. The mucous membrane is diffusely red^ 
especially at the introitus. The mucous membrane bleeds readily 
on mechanical irritation. In acute cases the secretion is purulent 
and mixed with the tenacious mucus of the glands of Bartholin. 
Purulent discharge from the urethra, punctate redness of the vulva, 
involvement of the glands of Bartholin, involvement of the peri- 
urethral glands, small red hypertrophies of the mucous membrane, 
speak clearly for the existence of a gonorrheal cause. With inflam- 
mations of the vulva ulcerations may occur. They are situated 
especially in the fossa navicularis, at the edge of the hymen, and 
in the circumference of the external meatus of the urethra. 

In chronic vulvitis there is little or no discharge. There are 
only masses of squamous epithelium. Sometimes a milky or puru- 
lent secretion can be expressed from the recesses and folds of the 
vulvar mucosa. In other chronic cases the mucous membrane 
is not so red, but evidences red spots and streaks at the border of the 
hymen, about the urethral orifice, on the outer surface of the hymen, 
and about the ducts of Bartholin. In still other cases there is 
little visible change resulting. Little remains of the original 
condition except evidences of the scratching, due to the itching. 

Vulvitis pruriginosa is often classed as a form of pruritus 
vulvae. Pruritus vulvae is generally a secondary condition and 
attention must be paid to the cause. Among the causes are icterus, 
diabetes, irritating discharge from the vagina, cervix, or uterus,. 
masturbati on and endometritis with irritating fluor, and, in addition, 
the irritation of ammoniacal or pathologic urine. But there occurs 
in older women, at the climacterium, a condition which is really a 
chronic inflammation without any evident cause. Vulvitis prurigi- 
nosa is such a chronic inflammation of the vulvar mucosa in older 
women, with marked symptom of burning and itching. The 
mucous membrane and the surrounding skin are markedly inelastic 



442 MEDICAL GYNECOLOGY 

and furrowed into folds, especially about the clitoris. It has a 
bluish-gray color, sometimes very pale, in contrast to the surround- 
ing mucous membrane. Its main symptom is burning and itching, 
which are most markedly felt at night in bed. Scratching can 
scarcely be resisted, and there result excoriations and eczematous 
conditions. This form is not infrequently one-sided. It is to be 
distinguished from kraurosis vulvae. 

Kraurosis Vulvae. — This is an atrophic condition of the corium 
of the mucous membrane of the larger and the smaller labia and 
of the introitus. There first appear white spots on the surface of 
the mucous membrane, which later take on a sclerotic character. 
The mucous membrane becomes white, grayish, and atrophic; 
gradually the smaller labia and the clitoris shrink. The larger 
labia appear flat and the smaller labia seem almost absent. The 
clitoris is small and lies concealed under folds of atrophic mucous 
membrane. Pruritus is the only subjective symptom. Narrowing 
of the introitus results. It differs from vulvitis pruriginosa in two 
important respects: (i) There is a decided narrowing of the 
introitus; (2) the atrophic condition of the skin is marked. This 
is in contrast to the inelasticity and folded character of the skin in 
vulvitis pruriginosa. 

Diabetic Vulvitis. — This condition, which occurs in connection 
with diabetes and has itching for its marked symptom, is, as a rule, 
so typical in appearance that the diagnosis can be readily made. 
The entire skin covering of the larger labia and the smaller labia, 
the clitoris, and the vulva have a bronze or copper- colored leathery 
look and feel. These tissues are thickened but do not pit on pres- 
sure and they are elastic in character. Occasionally the condition 
is one of furunculosis. In every case of vulvitis the urine should 
be examined for sugar. 



THE TREATMENT OF VULVITIS 

In the treatment of catarrhal vulvitis the usually associated 
urethritis and vaginitis, etc., should be treated. For the vulvitis 
itself, local applications of dilute liquor plumbi subacetatis, or a 
solution of acetate of aluminum, give relief. After the acuteness 
is over, local painting with 5 to 20 per cent, solution of nitrate of 



vulvitis 443 

silver or the application of a 5 per cent, cocain salve is advisable. 
Cases beginning as intertrigo in fat women should be treated by a 
thorough washing with soap, followed by bichlorid solutions; then 
salve should be applied, either zinc ointment or 10 per cent, bis- 
muth subnitrate in oxid of zinc, or the area should be painted with 
10 per cent, silver. 

When first seen, the vulva in inflammatory vulvitis should be 
thoroughly washed with glycerin soap and water, making use of 
cotton sponges. The treatment of vulvitis demands absolute 
cleanliness and the correction of the cause. If it is secondary to 
conditions existing in the urethra, bladder, vagina, cervix, or 
uterus, these affections must be treated. In addition to the pre- 
liminary washing, the vulvitis itself is benefited markedly by warm 
sitz-baths taken twice daily for periods of fifteen minutes. Shaving 
of the hairy parts of the skin area involved is of great value. 
Twice daily douches should be taken, consisting of 1 dram of ace- 
tate of aluminum to 2 quarts of water. 

Acute gonorrheal vulvitis should be treated by cleansing of the 
external structures. Mild solutions of corrosive sublimate 1 : 5000 
to 1 : 10,000 should be used. The parts should be carefully sepa- 
rated and gently sponged with cotton soaked in this solution, 
each washing being followed by a vaginal douche of bichlorid 
of mercury 1 : 2000. Bichlorid gauze should then be placed in 
such a manner that the two sides of the vulva should be kept 
apart by a T binder gently applied. The patient should be kept 
in bed and sedatives should be administered four times a day. If 
the skin is sensitive and red and is irritated by the action of the 
bichlorid of mercury, the gauze dressing should be saturated 
with a solution of acetate of aluminum. In the subacute stage 
the vulva should be treated by the silver salts. It should be painted 
with argyrol 25 per cent., by nitrate of silver 10 per cent., and the 
surfaces should be kept dry by gauze dusted with dermatol and 
nosophen. 

Some of the cases are benefited if the two halves of the vulva are 
kept apart by gauze saturated with a 1 per cent, solution of acetate 
of aluminum. In other cases relief is obtained by saturating the 
gauze with a dilute solution of acetate of lead or a watery solution 
of 1 to 5 per cent, carbolic. When the acute stage is over, the 



444 MEDICAL GYNECOLOGY 

solution should be changed to i per cent, alum and the vulva should 
be painted with 15 to 10 per cent, nitrate of silver. 

In the treatment of chronic vulvitis attention should be paid to 
the area immediately around the external opening of the urethra. 
Any resisting inflammation about the urethra or a folliculitis of the 
same area must be treated by the actual cautery or by the nitrate of 
silver stick preceded by the use of cocain. 

Some of the cases do well on the application of salves. A 10 
per cent, ointment of bismuth subnitrate in a base of oxid of zinc or 
a 2 per cent, carbolic ointment is of value. Salves include a 10 
per cent, calomel ointment; 5 to 10 per cent, cocain salve (cocain, 
1 dram; lanolin, 1 ounce; olive oil, 2 drams) or menthol ointment: 
(menthol, \ dram; olive oil, 2 drams; lanolin, 1 ounce); a carbolic 
ointment, containing 15 grains of carbolic acid to 1 ounce of 
unguentum zinci oxidi; a 10 per cent, ointment of anesthesin. If 
this does not give relief, the parts should be kept dry by dusting- 
powders. In mild cases a powder composed of equal parts of 
oxid of zinc and starch is sufficient. A better powder is one 
containing 20 grains of salicylic acid to a half ounce each of oxid 
of zinc and starch. A very good powder consists of menthol 15 
grains, salicylic acid 1 dram, oxid of zinc 2 drams, . amy lum and 
talcum 5 drams. In the more stubborn cases the vulva must be 
painted with 10 to 20 per cent, solution of nitrate of silver. 

The treatment of vulvitis pruriginosa, of kraurosis vulvas, of 
diabetic vulvitis, and of the skin annoyances is given in the section 
on Pruritus Vulvae. 



COLPITIS OR VAGINITIS 

Etiology. — Newly born children by no means rarely acquire 
gonorrheal vulvovaginitis of various degrees of severity. Older 
children quite frequently suffer from gonorrheal vulvovaginitis. 
This condition is generally considered to be simply a vulvitis, 
when practically in every case, especially those cases which do not 
yield very quickly to treatment, the associated vaginitis is the im- 
portant condition. 

Diphtheria rarely, but much more frequently measles and 
scarlatina, may produce an acute involvement in the vagina of an 
eruptive, ulcerative, or hemorrhagic character, often unrecognized; 
and when noted, because of the bleeding, considered to be a preco- 
cious menstruation. 

In adults acute structural primary involvement of the vagina 
by the frequently inoculated gonococcus is not so easy. The 
thick squamous epithelium is much more resistant to the gonococcus 
than in children, with their tender, thin, vaginal epithelium, yet 
this involvement may take place primarily. Vaginitis is frequently 
secondary to involvements of the cervix and uterus by gonorrhea 
and catarrhal inflammations. Of course, all infecting bacteria 
must pass through the vagina before reaching the cervix and uterus, 
where they find a more favorable soil. In the vagina there comes 
into play the element of continued irritation. A secretion from 
the cervix and uterus, produced by any cause, such as gonorrheal 
or other infection, or by degenerating carcinoma or myoma, is 
constantly poured into the vagina, macerates the vaginal epithelium, 
and produces mechanical and chemical irritation and subsequent 
bacterial inflammation. 

Contributing Causes of Colpitis or Vaginitis. — The use of 
unclean pessaries, the presence of neglected tampons, injury to the 
vaginal mucosa from the pressure of pessaries, etc., may permit 
introduced bacteria or the various forms of bacteria present in 
the vagina to add the element of inflammation to the element of 
mechanical irritation. 

445 



446 MEDICAL GYNECOLOGY 

Infection of the vagina from the rectum by the bacterium coli 
or by saprophytes may occur in older women with lacerated peri- 
neums and non-resistant tissues. Prolapse of the vagina or cysto- 
cele in older women permits of irritation of the exposed vaginal 
mucous membrane, in addition to the natural tendency to senile 
vaginitis in that period. 

Vaginitis or colpitis is a catarrhal inflammation of the mucous 
lining of the vagina from the hymen up to the external os. Colpitis 
must be distinguished from hypersecretion. 

Hypersecretion occurs in pregnancy and with inflammations, 
exudates, and tumors situated near the vagina. It may also occur 
with chlorosis, with anemia, with the irritation of intercourse, and 
with onanie. Such secretion is pure white. All purely white 
secretions contain squamous epithelia. Serous discharge may 
come from the vagina. A milky serous secretion is characteristic 
of the vagina as a result of the serum which is thrown off from 
the capillaries of the papillae. Such a secretion results from an 
increased throwing off of squamous epithelium which forms 
white masses often accumulated on the surface of the mucosa as 
thick white particles. When these are removed, the character of 
the mucosa underneath is seen. 

Acute Colpitis. — Colpitis is recognized with the aid of the 
Ferguson speculum: (i) By the character of the vaginal secretion; 
(2) by changes in the mucous membrane. With acute infections 
there is a production of pus and the secretion takes on a touch of 
yellow. The more acute the process, the yellower and more puru- 
lent is the discharge. Pus is greatest in the granular colpitis of 
gonorrheal origin, especially so in pregnancy. Purulent secretion is 
not characteristic of the vagina alone, but may come from the uterus. 
The appearance of the vagina, however, generally shows whether 
the vagina is involved. Whenever there is doubt as to the source 
of the purulent secretion, a long vaginal cotton-gauze tampon should 
be used (Fig. 48). In colpitis the tampon becomes soaked with 
discharge and that part of the tampon which is in contact with the 
vagina is covered with pus. In the punctate form of colpitis the 
tampon shows a yellow spot corresponding to every involved point. 

In acute cases the mucous membrane is diffusely red. There 
is also, in addition to the diffuse redness, a spotted or streaky 



COLPITIS OR VAGINITIS 447 

hyperemia, due to a very strong injection of the papillary bodies 
of the mucous membrane. We see in the upper part of the vagina, 
red, ink-like spots, or red streaks, which represent the summit of 
the vaginal folds. The spots bleed easily and there are sometimes 
ecchymoses. With intensive inflammation the papillary bodies of 
the vaginal mucosa swell and the vaginal folds and papillae project 
above the surface of the mucosa. This is especially marked in 
the gonorrhea of pregnancy, and there results what is called a col- 
pitis granulans. 

In secondary colpitis, resulting from an infectious cervico- uterine 
catarrh, the discoloration of the vagina is most marked or often 
limited to the posterior wall of the vagina near the external os. 

Chronic Vaginitis. — If chronic hypertrophic conditions super- 
vene in the inflamed papillae, there may result condylomata acumi- 
nata, which are small excrescences with a white irregular surface 
which occur singly in the vagina or on the portio. In the mild or 
chronic forms of colpitis there may be varying degrees of milky or 
serous discharge. When this is removed, the red mucosa is seen 
underneath. In the mild or chronic forms of colpitis tiny red 
spots may be the only signs observed. 

Senile Vaginitis. — Spots and ecchymoses are most distinct in 
senile women, because of the thinned- out character of the vaginal 
squamous epithelium. Vaginitis senilis occurs frequently at the 
climacteric period and represents regressive changes in the mucous 
membrane, which becomes non-resistant to vaginal bacteria. 
There may be a diffuse redness of the mucosa, which is especially 
marked in the exposed mucosa if cystocele is present. There may, 
on the other hand, be erosion of the surface. The papillae are not 
prominent. There may result adhesions of the upper and lower 
vaginal walls or even atresia of the entire canal. These adhesions 
yield readily to pressure and are followed by a little bleeding. 

Colpitis Mycotica. — This condition may occur, especially in 
pregnancy, and is due to the leptothrix vaginalis or to the oidium 
albicans. The latter may cause an appearance simulating colpitis 
with epithelial desquamation. It occurs most frequently in preg- 
nancy and forms white spots, generally at the summit of the vaginal 
folds. These are not easily wiped off, and when removed uncover 
red inflamed areas which bleed readily. Microscopic examination 



44-8 MEDICAL GYNECOLOGY 

in diluted potassium hydroxid solution sometimes shows only 
squamous epithelium, but often reveals the mycelium oidium 
albicans. 

Colpitis Emphysematosa. — In pregnancy especially there may 
occur the formation of gas vesicles in the mucosa, generally situated 
on the posterior wall, due to the activity of gas-producing bacteria 
and called colpitis emphysematosa. 

In colpitis there may occasionally occur an exfoliation of part 
of the mucous membrane. This occurs, as a rule, after the appli- 
cation of drugs, such as several coats of iodin. Microscopic 
examination distinguishes this membrane from intrauterine exfolia- 
tions, with which it may be confused. 



DIAGNOSIS 

The symptoms of an acute colpitis are local heat, a sensation of 
burning, and pressure. Coitus is painful. There is usually an 
associated vulvitis which causes burning with intertrigo. In the 
acute cases these symptoms are generally in the background because 
of the severity of the associated external or higher infections. In 
children the symptoms are those of vulvitis. Even in gonorrheal 
vulvitis, with the exception of some burning and irritation, the 
annoyance felt by the little patients is very slight. 

In colpitis the examining ringer may feel the rough character 
of the vagina, due to the projections on the transverse folds of the 
vagina. When infiltration takes place on the transverse folds or 
in the papillae, the vagina feels like a file to the examining ringer. 
When there is diffuse redness, the vagina may feel as smooth as 
moss. In other cases the ringer simply notes- the heat of inflamma- 
tion. In the mild forms of colpitis, associated with epithelial 
desquamation, the examining finger notes the dried particles 
which cover the entire vaginal mucosa. Often the ringer notes 
nothing, especially in the senile vaginitis, because in them the papillae 
are not prominent. The symptom of chronic colpitis is simply 
fluor albus. Senile vaginitis, which is often combined with 
cystocele, results in itching and burning and some bleeding on 
examination or on the use of rings. The diagnosis of colpitis is 



COLPITIS OR VAGINITIS 449 

to be made by the finger, but especially with the eye and micro- 
scope. 

TREATMENT OF VAGINITIS 

The vaginitis associated with acute infectious diseases should be 
treated by daily douches of 1 per cent, carbolic acid. 

In acute vaginitis the patient should have rest in bed, the external 
genitalia should be thoroughly cleansed, tepid sitz-baths should be 
taken daily. Alternate tepid douches of bichlorid of mercury, 
1 : 2000, and acetate of aluminum, 1 dram to 2 quarts, should be given 
four times daily, and gauze soaked in 1 : 5000 bichlorid or in 1 per 
cent, acetate of aluminum should be applied to the perineum and 
vulva. If the irritation is marked and if the treatment of the 
vaginitis demands sedative and antiseptic douches, thymol 1:1000, 
permanganate of potash 1 : 1000, and i per cent, ichthyol should be 
substituted for the bichlorid. In addition to the above solutions, 
acetate of lead is of value in the strength of 1 to 2 per cent., or 
Lugol's solution 1 to 2 drams to the quart, or pyroligneous acid 
1 to 4 drams to the quart. Internally bromids and opium should 
be administered. When the primary inflammation and sensitive- 
ness is diminished, hot douches of bichlorid of mercury or 1 to 2 per 
cent, carbolic acid are of value. In the case of sensitive vagina, 
ointments containing carbolic acid 1 per cent, or ichthyol 5 per cent, 
may be used at first. If the vagina is not too sensitive, it should be 
washed with the aid of a Ferguson speculum with sponges soaked 
in a carbolic solution, and gauze soaked in 1 to 5 per cent, protargol 
should be introduced into the vagina and left in place for several 
hours. Still later the vagina should be bathed, with the aid of a 
Ferguson speculum, by solutions of nitrate of silver 1 per cent., and 
the vagina should be gently packed with sterile gauze or iodoform 
gauze left in place for twenty-four hours. Then irrigate daily 
with alum 2 per cent, or permanganate of potash 1 : 1000. In the 
chronic persisting forms of vaginitis the Ferguson speculum should 
be used and nitrate of silver should be applied in stronger solutions. 

In very chronic cases if silver, 1 per cent, or stronger, fails, paint 

vagina every two or three days with tincture of iodin or silver 5 to 

10 per cent., pack the vagina with gauze, and continue the treatment 

till vaginal epithelium desquamates. Hot douches should - then con- 

29 



45° MEDICAL GYNECOLOGY 

sist of tannic acid, sulphate of zinc, or alum i dram to the quart. 
Splendid results are to be had by bathing the vagina, with the aid 
of the Ferguson speculum, with bichlorid of mercury i : ioo, 
rendered acid by a few drops of hydrochloric acid. Then pack 
with iodoform gauze or gauze dusted with dermatol, and repeat 
twice a week. In the meantime irrigate with i : 5000 to 1 : 2000 
bichlorid or with tannic acid, sulphate of zinc, or alum. This 
treatment is effective in hypersecretion, especially if associated with 
endocervicitis and fibrosis uteri. Nitrate of silver solutions exert an 
astringent influence when applied with the aid of the Ferguson 
speculum. Iron and tonics should be given for anemia. Pelvic 
congestion should be relieved by sitz-baths and the uterus should be 
supported by intravaginal pressure therapy, and later on by a pes- 
sary. (See pages 114, 99, and the sections on Leukorrhea and on 
Gonorrhea.) 

In that chronic form known as colpitis granulosa, first clean 
the vagina with the aid of the Ferguson speculum and then use 
pyroligneous acid in the Ferguson speculum, rubbing it well into the 
vaginal mucosa with cotton on a swab. This should be done two 
or three times a week. 

Senile Vaginitis. — Bathe the vaginal walls thoroughly with 
pyroligneous acid three times a week for several weeks through the 
Ferguson speculum. Daily douches of pyroligneous acid, 1 to 
3 drams to the quart, are to be ordered. No pessary is to be worn. 

For colpitis mycotica 1 per cent, corrosive sublimate or three per 
cent, carbolic should be applied with the aid of the Ferguson 
speculum. 



ENDOCERVICITIS OR CERVICAL CATARRH 

Etiology. — An inflammation in the genital tract may be pro- 
duced by tubercle bacilli which may reach this focus of develop- 
ment through the medium of the circulation. The tubercle 
bacillus, as a rule, however, enters the genital tract subsequent to 
its presence in the peritoneal cavity, being then attracted by the 
ciliated epithelium into the tubes or uterus. Appendicitis with its 
exciting streptococci, staphylococci, or bacterium coli may, as a 
consequence of the resulting peritoneal exudation, likewise send its 
bacteria or cocci into the follicles of the ovary, or else into the tubes 
and uterus, through the action of the ciliated epithelium in their 
lining. The diseases of children, such as measles, scarlatina, 
mumps, etc., are known to produce, not so very rarely, unrecognized 
inflammation in the ovaries, tubes, or uterus, with resulting tempo- 
rary or permanent structural and functional involvement of these 
organs. Scarlatina, diphtheria, measles, etc., may produce acute 
invasions of the uterus or necrotic lesion in the cervix or vagina 
with resulting annoyances in the way of stenosis and atresia. With 
these exceptions the bacteria which produce infection of the genital 
tract must first pass through the cervix. It is therefore of impor- 
tance to study the cervix and its infections, and in addition to note 
the various lesions which may follow as sequelae from this primary 
point of involvement. 

Infection of the cervix in labor, in abortion, or in operations on 
the cervix and uterus may lead to various inflammations, such as 
endocervicitis, endometritis, metritis, salpingitis, oophoritis, peri- 
tonitis, true septicemia, pyemia, phlebitis, and local involvement of 
the cellular connective tissue of the pelvis. Frequently we find an 
exudative or purulent involvement of one or both broad liga- 
ments, due to infection through lateral tears of the cervix, or else we 
find an inflammatory accumulation in the posterior parametrium 
or in the uterosacral ligaments. Any or all of these conditions 
may be due to infection during labor, abortion, or operations on the 

451 



452 MEDICAL GYNECOLOGY 

cervix, and are of not infrequent occurrence. It must be remem- 
bered that previously present or introduced streptococci and 
staphylococci, or sometimes the bacterium coli, are frequently the 
agents which produce those pathologic conditions as well as the 
localized abscess formations in the cellular connective tissue. 
When the inflammation subsides, with or without operation, these 
infecting cocci and bacteria have a tendency to disappear, although 
they may continue in the uterus and cervix and though structural 
alterations may remain. If, as so often happens, the gonococcus 
be present before labor, abortion, or operation, it may then pro- 
duce or take part in any of the above-mentioned affections, but the 
gonococcus does not subsequently disappear so readily. Condi- 
tions which produce congestion in the genital tract seem to favor 
the continuance of the growth of bacteria. For instance, the gono- 
cocci may be found by careful examination after menstruation 
in the secretion of the cervix and uterus when not found at other 
times. Excessive coitus may keep up or stimulate any of the 
inflammations present in the genital tract. Exertion, work, and 
lifting have the same influence. In gonorrhea, especially in the 
older cases, the staphylococcus is often found playing a part in 
keeping up the chronic lesions. In such instances the gonococcus 
may disappear, at least so far as microscopic evidences are con- 
cerned. It is well known that in pyosalpinx after a certain period 
the gonococci disappear, and either streptococci or staphylococci 
are found or else the pus is perfectly sterile. That the cervix 
then may contain various forms of bacteria, or that they may enter 
the cervix from the vagina in abortions, labors, operations, etc., 
is certainly true in many cases. 

Leaving aside the discussion of affections that occur under the 
conditions of labor, abortion, or operations, and dealing with acute, 
subacute, or chronic involvements of the cervix under other cir- 
cumstances, we are forced to the conclusion that the latter involve- 
ments are due in the very vast majority of cases to the presence and 
development of the gonococcus. 

In the female various forms of bacteria are present in the vulva. 
In the urethra streptococci, staphylococci, and bacterium coli are 
frequently present and may be introduced into the genital tract. 
The normal vaginal secretion has an acid reaction and contains 



ENDOCERVICITIS OR CERVICAL CATARRH 453 

epithelial cells, various forms of bacilli, and yeasts and cocci. 
The normal vaginal secretion and the normal resistance of the 
squamous epithelium have the power, as a rule, to resist the in- 
vasion of various micro-organisms introduced from the vulva or 
by coitus or by examination. This resistance varies in different 
individuals and in different periods of life. A pathologic secretion 
contains leukocytes in addition to the squamous epithelia and 
various forms of bacteria, among which may be streptococci and 
staphylococci and gonococci. In older women and in senile 
women bacteria and cocci other than the usual ones may be present 
in the vagina and also in the cervix and uterus. When once the 
genital tract is the seat of a gonorrheal infection, however, the 
various pathogenic organisms which are usually destroyed when 
introduced into the vagina find opportunity for existence not alone 
in the vagina but also in the cervix and possibly in the uterus. 
Normally the upper part of the cervix and the uterus contain no 
bacteria, but when gonorrhea has once invaded the cervix and 
uterus conditions are altered. 

Infections of the cervix very frequently occur in nulliparae under 
circumstances not related to labor, abortion, or operation. Nor- 
mally the upper part of the cervix and the uterus contain no bacteria. 
The cocci and other micro-organisms which usually enter the vagina 
through lack of cleanliness or through the physical relation of coitus 
are destroyed by the resistance power of the vagina. When, 
however, through the male urethra, a pathologic seminal or pros- 
tatic secretion is continually being deposited in the fornices, the 
ability of the vagina to rid itself of micro-organisms is not absolute, 
nor does it protect the cervix and its lining. The pathologic 
seminal or prostatic secretion may contain gonococci or strepto- 
cocci or staphylococci, and in very rare instances tubercle bacilli. 
A chronic prostatitis originally gonorrheal may be complicated by 
the presence of pus cocci, complicating the original disease 
either as a mixed infection or as a secondary infection. That 
some cases of cervical involvement may thus result from strepto- 
cocci or staphylococci, is quite probable. While the gonococcus 
may play an important acute role in the production of mucous 
membrane, subepithelial, peritoneal, and systemic involvements, 
with or without relation to pregnancy and the puerperium, yet the 



454 MEDICAL GYNECOLOGY 

gonococcus most frequently plays a subacute and generally un- 
recognized role in the production of chronic, stubborn, or perma- 
nent affections of the mucous membranes, the myometrium, the 
peritoneum, or the pelvic cellular connective tissue. The point 
of primary infection in these conditions is the cervix. Hence, in 
addition to being the original focus in the production of many 
acute inflammations, the cervix plays a most important part as a 
portal of infection in the transmission of those subacute and chronic 
inflammations in the female, which even today are so little under- 
stood. 

When a male suffers from gonorrhea, there is a purulent dis- 
charge, burning micturition, pain, and many complicating troubles 
and dangers so soon as the inflammation passes to the posterior 
urethra. (The gonococci are most readily found.) Light cases 
are such as heal in a few weeks and do not extend to the posterior 
urethra. They heal quickly because the infecting gonococci are 
not virulent, or because the individual is not particularly suscepti- 
ble and because the condition is limited to the anterior urethra. 
In women, too, infection by the gonococcus may begin with virulent 
acuteness in the cervix, yet patients may not seek medical aid unless 
the urethra or glands of Bartholin are affected, or unless the uterus 
or tubes and peritoneum are involved by a virulent rapid upward 
extension, which upward extension may occur in spite of great 
care, but which is often furthered by pelvic congestion, overexertion, 
intracervical or intrauterine manipulation. 

In virulent cases of gonococcus infection in women, when the 
activity of the inflammation is entirely or superlatively carried on 
in the uterus, tubes, connective tissue, or peritoneum, the cervical 
affection for the time being is a negligible quantity. The evidence 
of inflammation in the cervix is then scarcely needed as an aid to 
diagnosis. After the acuteness of the associated complications 
has disappeared the cervical condition may furnish corroborative 
evidence, yet the other lesions enable us to make the diagnosis. 

Acute Endocervicitis. — When, however, an acute endocer- 
vicitis, in the discharge from which gonococci can be readily found, 
remains limited to the cervix alone, it causes relatively few symp- 
toms. The cervix looks shiny, it is somewhat sensitive to pressure, 
there is a mucopurulent discharge, there is a red inflamed area 



ENDOCERVICITIS OR CERVICAL CATARRH 455 

about the external os, and gonococci can be readily found in the 
pus cells. We rarely see such localized cases early because the 
symptoms, when the disease is located in the cervix alone, are 
very few. 

When such acute cervix cases to come to hand, some come per- 
haps of a complicating urethritis and painful burning micturition, 
yet many women having a gonorrheal urethritis bear with the 
associated annoyances, which gradually become less and either 
continue as a subacute process or finally heal without attention on 
the part of a physician. Other patients come because of a 
complicating Bartholinitis with gonococci in the secretion, which 
is only accidentally discovered, as the duct is not closed and an 
abscess in the gland is not found. It is the external complications 
which bring such patients to the physician, and it is then that an 
acute localized endocervicitis is usually brought to light. Such 
cases located in the cervix may pass on, of themselves or by con- 
servative treatment, to the subacute or chronic form. 

It is to be remarked that cases of virulent involvement of the 
uterus show slight evidences in the cervix. There is little mucus 
and cervical discharge. It seems as if in such cases the cervix in 
its reaction to the gonococcus invasion showed but little resistance, 
because it was stimulated to the secretion of but little mucus, and 
thus infection was permitted to spread readily upward. In those 
cases with the greatest catarrhal involvement of the cervix the cervix 
has reacted to the gonococcus invasion by the production of much 
mucus, and upward extension is either prevented or is made of a 
very mild character. Then we find the changes which give us 
the picture of chronic catarrh with discharge, erosions, inflamma- 
tory ectropion, etc., yet examination at this later stage divulges 
gonococci only after great care or after a recrudescence, and most 
often not at all. 

Subacute Endocervicitis. — Most cases of cervical infection, 
however, are innocently acquired from a supposedly cured or 
supposedly harmless prostatitis in the male, and they naturally 
begin in a subacute form. (The rule of Wertheim does by no 
means always apply.) It is in the subacute cases that close study 
of the cervix plays a most important part in furnishing the local 
evidences of the existence of an inflammation which, perhaps, has 



456 MEDICAL GYNECOLOGY 

been slowly extending into the genital tract. There is nothing to 
suggest a marked involvement, or there is nothing to suggest gonor- 
rhea as it is generally pictured. Examination by microscope shows 
no gonococci and often few pus cells. If the inflammation extends 
upward slowly to the uterus or tubes, such subacute cases seek 
medical aid because of sterility or because of pain due to involve- 
ment of the peritoneum or to involvement of the cellular connec- 
tive tissue. These extensions often come on after intrauterine 
manipulation or after labor or abortion, which latter condition is 
of itself so often due to a mild uterine catarrh and the conse- 
quent endometrial and decidual changes. Though no bacterial 
infection can occur in the uterus from below without first passing 
the cervix, yet in many cases distinct evidences in the cervix are 
lacking. In many cases where the condition has extended higher 
up, very slight evidences are present in the cervix, and the diag- 
nosis must be made from the presence of even the slightest 
accessory lesions in the genital tract. In other instances the 
entire condition is limited to the cervix at the time of examina- 
tion. Especially here, recognition of the existence of an infection 
in the cervix is important: (1) Because the cervix furnishes the 
original focus; (2) because from this focus pass out the inflam- 
matory elements which continually infect the connective tissue 
about the uterus; (3) because we thus obtain corroborative proof 
of the existence of an inflammation which may have passed 
higher up without any elements of acuteness and without causing 
any pain whatsoever. If the higher parts are markedly affected, 
they dominate the situation. If the cervix alone is affected, its 
conservative treatment is of doubly great importance. By proper 
care we may avoid that upward extension which yields negative 
symptoms in the form of sterility, or positive symptoms in the form 
of pain. Sterility due to salpingitis, and yet unassociated with 
pain, is often a symptom, and we must look for evidences of a 
causal inflammation. This cause is generally a cervical catarrh 
produced by the secretion of a chronic prostatitis. 

Evidences of Cervical Catarrh. — What are the evidences of 
cervical catarrhal inflammation ? 

Normal Cervix. — The normal cervix is covered by smooth 
vaginal, squamous mucosa. The wall is composed of muscle 



ENDOCERVICITIS OR CERVICAL CATARRH * 457 

fibers; its canal is lined with high cylindric ciliated epithelium 
which secretes mucus of a clear, glairy nature. The external os 
marks off a fairly clear line of division between the squamous 
epithelium of the outer covering and the cylindric epithelium of 
the canal. The line of delimitation is generally as sharp as that 
observed between the skin and mucous membrane of the lips. The 
cervix is not hard and the area of the internal os, except in some 
cases of congenital retroversion and elongatio colli, presents an 
elastic line of division between the cervix and fundus. The cervical 
portion of the uterus is embedded in connective tissue, and six 
ligaments filled with connective tissue and rich in lymphatics are 
connected with the cervix — the two broad ligaments, the two 
uterovesical ligaments, the two uterosacral ligaments. These, with 
the connective tissues about the cervix and the subperitoneal 
connective tissue which lines the pelvis, constitute the parametrium 
or pelvic cellular connective tissue. The cervix is freely movable 
and no sensitive points or. infiltrations are felt about it. The nor- 
mal cervix may be pushed up toward the symphysis, pushed back 
toward the sacrum, pushed toward the lateral wall of the pelvis, 
without pain and without limitation of mobility. 

Variations from the Normal. — We may study the variations from 
the normal which are produced by mild or chronic cervical infec- 
tion by observing: (1) changes in the squamous mucosa covering 
the cervix; (2) changes in the area of delimitation between the 
cervical fining and the squamous covering of the cervix; (3) 
changes in the cervical lining ; (4) changes in the surrounding con- 
nective tissues; (5) changes in the cervical wall. Other higher 
lesions in the genital tract pass out from this original focus of in- 
flammation and present negative or subjective symptoms, as well 
as tangible lesions. 

We are therefore concerned (1) with objective evidences, (2) 
with subjective evidences or symptoms. 

Objective Evidences. — Under objective evidences we have: (1) 
changes in the squamous covering of the cervix in the form of 
erosions; (2) redness and signs of inflammation about the external 
os; protrusions of the cervical lining; inflammatory ectropion; 
(3) changes in the cervical lining produced by catarrh, which are 
evidenced by swelling of the mucous membrane and by the existence 



458 MEDICAL GYNECOLOGY 

of a pathologic discharge; (4) changes in the connective tissue 
in the form of parametritis; (5) changes in the cervical wall in the 
form of ovula of Naboth or of diffuse hypertrophy; (6) over- 
growths of cervical mucosa in the form of polyps. 

The Vaginal Form of Cervical Catarrh.— The vaginal por- 
tion of the cervix is covered with stratified squamous epithelium, 
under which are but few papillae. The lowest layer of cells, 
the layer which separates the squamous epithelium from the 
connective tissue, is composed of low cylindric cells and is the so- 
called formative layer or stratum germinativum. The tissue under 
this epithelium is connective tissue rich in nuclei. The deeper 
layers are formed of muscular tissue radiating from the corpus 
uteri and forming the main structure of the cervix. Inflam- 
mation of the cervix is of either the vaginal or the cervical type. 
The former means inflammation of the outer covering of the 
cervix, and is part of a vaginitis. In the vaginal form we observe 
redness or red isolated points or papillary areas, like those ob- 
served in vaginitis. Such factors, except in old women, speak for 
a gonorrheal etiology. In inflammation of the vaginal portion of 
the cervix the capillaries are turgid. New capillaries are formed 
under the surface and there is a grouping of round cells, 
especially around the new capillaries. Numerous papilla? are 
formed which pass up to the surface and are supplied with 
turgid capillaries, thus giving the red color to the surface. 

The Cervical Form. — The second type may be called the cervi- 
cal form, in which erosions are often present in conjunction with 
and due to a cervical catarrh. When smooth vaginal mucous 
membrane does not cover the entire surface of the vaginal portion 
of the non-lacerated cervix, but suddenly ceases, giving place to 
smaller or larger very red, uneven, and slightly bleeding spots, 
we are concerned with a pathologic state. This affection is gener- 
ally situated immediately around the external os in its entire 
circumference. The red base is either depressed or else rises 
above the surface in the form of excrescences. Because of the 
external appearance, these lesions are called erosions. They 
must be distinguished from inflammation of the vaginal portion, 
from ulcers, and from ectropion. 

Erosions mean that the vaginal part of the cervix which is 



ENDOCERVICITIS OR CERVICAL CATARRH 459 

normally covered by squamous epithelium evidences in the cir- 
cumference of the external os the presence of cylindric epithelium 
to varying extents. Cylindric epithelium grows out from the 
cervical lining and takes the place of destroyed squamous epithe- 
lium. (1) In place of squamous epithelium we may have cylindric 
epithelium with a few glandular structures in the stroma. This is 
known as a simple erosion. (2) If the cylindric epithelium passes 
deep into the stroma and then rises again, etc., a papillary appear- 
ance is given and we have what are called papillary erosions. 
(3) If the surface is smoother, but glandular dilatations are present 
among epithelial depressions, we have what is known as follicular 
erosions. 

In the early stages the stroma shows a small-celled infiltration. 
Therefore, in erosions, in place of the vaginal mucous membrane 
of the vaginal portion of the cervix and in a stroma normally free 
of glands, cervical epithelial cells with glands are present, showing, 
however, productive inflammatory changes. The theories which 
account for the origin of erosion are as follows : 

Theories as to the Origin of the Erosions. — (1) The theory 
of Fischel: In the newly born, he says, the outer surface of the 
vaginal covering of the cervix is of cervical structure. Either ihis 
infantile habitus persists, or else squamous epithelium later makes 
its way over these areas and grows over the cylindric epithelium. 
When later on irritation occurs, it stimulates these once buried 
cylindric cells to growth and they appear on the surface. 

(2) The theory of Ruge and Veit: They say that the cylindric 
surface epithelium with the depressions into the stroma originates 
from the formative layer and stratum germinativum of the squa- 
mous epithelium. The upper layers of the vaginal cervical cover- 
ing are thrown off in erosions and the formative layer remains 
as an independent covering in the form of cylindric epithelium. 

(3) Abel asks why this lowest layer, which usually forms only 
squamous epithelium, should suddenly form cylindric epithelium. 
Fischel's theory explains some cases when the erosions are situated 
at a distance from the external os or form isolated islands. Abel 
says that an irritation causes the cervical epithelium to proliferate, 
and that this growth displaces the squamous epithelium. In 
most cases cervical catarrh is present. 



460 MEDICAL GYNECOLOGY 

I hold that the continued discharge of a cervical catarrh macerates 
the squamous epithelium, which is thrown off, and replaced by the 
cervical epithelium engaged in proliferation. This new epithelium 
then produces glands here, just as it normally does in the cervix. 
Whichever of the theories be correct, erosions are an evidence of 
an inflammatory catarrh in the cervical canal. 

The Meaning of Erosions in Nulliparae. — In nulliparae 
especially, the presence of erosions speaks for a gonorrheal catarrh 
of the cervix. In women who have borne one or more children, 
and in whom perhaps other bacilli or bacteria may have been 
introduced, it is possible that a catarrh causing erosions may have 
other than a gonorrheal etiology. In women who have borne 
many children and in whom hypertrophy of the cervix is marked, 
and in whom lateral tears are slight, we may observe the area of 
the external os to have a somewhat red look and to be covered with 
many very small hard follicles. The cervical canal is roomy. 
There is secreted a clear tenacious mucus. Posterior parametritis 
chronica is never marked. Nothing suggests the degree or intensity 
of irritation observed in erosions or in inflammatory ectropion. 
It is conceivable, in fact, it probably happens often enough, that a 
cervical catarrh may go on to relative healing. Dilatation of the 
cervix by labor, the ironing out of the cervical recesses, and hyper- 
trophy of the cervix give good ready drainage to the canal. Succes- 
sive pregnancies are followed by further dilatation and hypertrophy, 
and the final picture is by no means like that observed in sterile 
nulliparae, in whom, in all probability, cervical catarrh by upward 
extension has rendered pregnancy improbable. Many of such 
cases in multiparas have been originally gonorrheal. 

In older women and in women at the menopause new changes may 
take place about the cervix, if laceration exists, which partake of 
the nature of the changes occurring in the vagina — senile vaginitis. 
The longitudinal folds of the cervical mucous membrane may 
give the external os a furrowed pinkish look, but hypertrophy and 
infiltration are absent. 

Redness and Signs of Inflammation About the External 
Os. — Though the point of junction of the squamous epithelium of 
the portio with the cylindric epithelium of the cervical canal is not 
always a certain one, yet the point of transition can be macroscopi- 



ENDOCERVICITIS OR CERVICAL CATARRH 461 

cally recognized. In the presence of an inflammation we observe 
sometimes a tiny ring of glazy redness and edema around the exter- 
nal os in nulliparae. This symptom, though slight, is of very great 
importance. In other cases this margin of redness is a little wider 
and its edge is not regular, but looks frayed. This is probably 
due to the longitudinal folds present in the cervical canal. In other 
cases in nulliparae or in women with non-lacerated cervices there 
is a slight protrusion of red inflamed mucous membrane on the 
anterior lip and the posterior lip just within the external os. There 
may be much secretion within the cervix of a very thick, extremely 
tenacious, white mucus. With this red glazed area of redness 
about the external os, however, little secretion is generally noted. 
The Schultze tampon must be used. In the case of nulliparae 
without lacerations the external os is dilated, the cervix is some- 
what hypertrophic and edematous, and the slightly everted mucous 
membrane looks red and irritated and shows all the evidences of 
inflammation. 

Ectropion. — The lining of the cervix is composed of cylindric 
ciliated epithelium which forms depressions in the shape of the 
well-known cervical glands. The cervical lining is arranged in 
longitudinal folds, beginning at the internal os and forming the 
arbor vitae or plicae palmatae. 

The epithelial cells are long, with transparent protoplasm, and 
are narrower at the base and have their nucleus at the base. The 
stroma of the cervical lining is, in addition, rich in cells only directly 
under the cervical epithelium, for the main element of the cervical 
wall is composed of muscle fibers into which project the base of the 
glands. 

Ectropion means that the mucous lining of the cervical canal, in 
lateral lacerations of the cervix, has been everted. The everted 
mucous membrane shows to the eye the state of the cervical canal. 
If no catarrhal infection is present, the exposed cervical lining 
undergoes epidermoid changes and looks like squamous epithelium. 
With catarrhal inflammation we get a red, inflamed looking area 
which is known as inflammatory ectropion. 

Secretion. — The normal secretion of the cervix is a glairy, tena- 
cious, clear mucus, ofttimes large in amount, in which event we 
are dealing with hypersecretion. This is often the result of con- 



462 MEDICAL GYNECOLOGY 

gestion and not infrequently of onanie. When, however, an infec- 
tion is present, the secretion is increased in amount and in character. 
It becomes either white or generally grayish, but may be yellow 
or green, showing variations in proportion to the acuteness or 
virulence of the infection. In every case the amount and character 
of the cervical discharge should be noted. The vagina and outer 
cervix should be thoroughly cleaned and then some of the cervical 
secretion should be removed and examined. In some cases where 
the canal of the cervix contains no mucus at the time, gentle 
suction by a modified breast-pump gives further information as to 
the contents of the cervical canal and yields very valuable informa- 
tion (Figs. 12, 13). When the amount of the secretion in the 
cervix is great, the cervical canal is usually dilated and enlarged. 
In other cases the amount of the secretion is not profuse, and it is 
of the greatest importance, in these as well as in all cases, to 
make use of the Schultze tampon, in order to determine the 
amount of discharge and to distinguish between the amount of 
secretion coming from the vagina and that which comes from the 
cervix and the uterus. 

Examination of the Secretion. — A square cotton tampon is 
placed carefully and thoroughly around the cervix and left in place 
for twenty-four hours. This tampon is then removed with the 
aid of a bivalve speculum and whatever secretion is found in the 
center of its upper surface has come from the cervix and the uterus. 
If the pathologic secretion comes only from the cervix, it will be 
entirely mucoid in nature and will be colored. If, however, the 
secretion comes from the cervix and uterus, there will be, in addi- 
tion to the mucoid secretion, a non-mucoid secretion from the 
uterus; the two, however, not being mixed. If the secretion comes 
from the uterus alone, we have a non-mucoid discharge on the 
tampon. The mucous secretion on the tampon or the secretion 
from the cervix drawn from it by suction is spread upon a glass 
and stained. We find, then, mucus, various forms of bacteria and 
bacilli, pus cells, high cylindric cells from the cervix, low cylindric 
cells from the uterus, very often squamous epithelial cells due to 
metaplasia of the ciliated cylindric epithelium of the cervix or 
uterus, and in some cases gonococci. Examination of the mucoid 
secretion is not satisfactory, for the reason that most of the cells, 



ENDOCERVICITIS OR CERVICAL CATARRH 463 

epithelial, squamous, or pus cells, are enveloped by the mucus and 
their shape and form are frequently disturbed. Gonococci, bacte- 
ria, or bacilli are almost never found in the mucus itself. If after 
careful cleansing of the outer covering of the cervix, squamous 
cells are found in the secretion obtained from the cervix or by suc- 
tion, that fact is corroborative of the existence of an inflammation, 
generally gonorrheal, for a chronic gonorrhea often produces a 
change to squamous epithelium in the lining of the cervix, frequently 
in the uterus. In old cases of gonorrhea or in cases subacute from 
the beginning, and especially in cases which are not treated by 
intracervical or intrauterine manipulation, it is extremely difficult 
to find gonococci, even when the examination is carried on shortly 
before or shortly after menstruation. In spite of the fact that in 
chronic gonorrhea at times a clear mucus may be passed, an inflam- 
matory cervical catarrh can be generally diagnosed definitely by 
anomalies in the secretion. 

As to glandular changes, we may have hyperplasia, yet the change 
is slighter than in the uterine mucosa. The round-celled infiltra- 
tion of the mucosa of the cervix is generally superficial, but as the 
infecting bacteria enter the glands they produce infiltrations about 
the glands. The interstitial changes, however, are enough to 
obstruct the outflow from the glands and to cause cysts. 

The cervix reacts to inflammatory irritation by the production of 
mucus. Hence, there are frequent cystic dilatations of the cervical 
glands, and we get cysts, follicles, and the ovula of Naboth. 
Through such dilatations and through their rising above the sur- 
face, we may get follicular polyps. 

Ovula of Naboth. — (i) Where erosions are present on the 
vaginal portion, the ciliated epithelium which is present sinks 
deeper into the outer wall of the portio, its glands become obstructed 
at the outlet, and accumulations of mucus form little projections 
above the surface. These may eventually be covered by squamous 
epithelium. When the cervix has for a long time been the seat of 
catarrh, it may happen that the outlets of the glands which line it 
become obstructed. The cervical glands of themselves are en- 
larged and elongated, and sink deeper into the wall of the cervix. 
Such obstructed glands may still further burrow their way through 
the cervical wall until their base extends out, close under the squa- 
mous covering of the vaginal portion. 



464 MEDICAL GYNECOLOGY 

When erosions are present, this condition can be readily diag- 
nosed, for we have a red granular surface present which renders 
the diagnosis of the etiology easy. In that form, however, which 
is due to the growth of the glands within the cervix the portio has 
no red irritated appearance, but under the squamous epithelium 
can be seen these single or multiple cysts projecting above the 
surface. When these projections are incised, a little glairy mucus 
is extruded. Their significance then is that they call attention 
either to changes in the intracervical glands or to change produced 
on the portio by extension thereon of ciliated cylindric epithelium. 

Hypertrophy of the Cervix. — There are cases in nulliparae in 
whom the existence of a chronic inflammation within the cervical 
canal produces structural changes in the wall of the cervix. The 
cervix becomes hard or rigid. These changes in nulliparae, how- 
ever, are not marked, for that would imply a deep extension of the 
inflammatory condition. Most of the involvement in such inflam- 
mations within the cervix is limited to the surface. The increased 
mucus discharge usually limits the infection to the surface or to the 
glands and prevents an extension into the muscular wall. How- 
ever, by continued hypertrophy of the mucous lining, or by the 
continued extension of the inflammatory process beyond the area 
of the mucous membrane, inflammatory and fibrotic changes are 
produced which render the cervix hard, much thicker, and much 
larger in circumference. This more extensive form of hyper- 
trophy of the cervix is observed in women who have borne one or 
more children. In them the cervix may be hypertrophied out of 
all proportion to the hypertrophy which has taken place in the 
remainder of the uterine wall. In a goodly number of cases the 
uterus, while more or less enlarged, is little changed in proportion 
to the tremendous high hypertrophy which involves the cervix. 
These changes in the cervix are found in women who have gone 
through frequent labors, and represent long-continued mild inflam- 
matory involvement plus the hypertrophy of subinvolution so 
frequently resulting from numerous labors. That this condition, 
however, is generally dependent on an inflammatory process is 
shown by the frequency with which this hypertrophy is compli- 
cated by a chronic involvement of the posterior parametrium. 

In women who have borne children a hypertrophy of the cervix 



ENDOCERVICITIS OR CERVICAL CATARRH 465 

is often associated with a hypertrophy of the uterus also. The 
uterus is long and rigid. The everted cervical mucosa is pink or red, 
generally smooth, but often contains many white or yellow granular 
projections, like those observed in the throat and on the tonsils. 
Not infrequently pedicled or broad-based cervical polyps are 
present. A clear glairy mucus is noted. The canal is dilated. 
The change in the cervix is due to subinvolution and fibrosis of 
the cervix and uterus. There are no evidences of inflammation 
about the uterus. There is no posterior parametritis. The mucus 
shows no pathologic change. It is possible that streptococci, staphyl- 
ococci, or bacterium coli of saprophytic type may be introduced 
into the cervix, and may alter the character of the cervical mucus, 
but, as a rule, this cervical secretion represents hypersecretion. 

We must distinguish therefore hypertrophy and posterior para- 
metritis due to cervical catarrh from hypersecretion present in 
a hypertrophied cervix due to subinvolution. If the cervix is 
enlarged and the uterus is normal, it speaks for the former. If 
both cervix and uterus are enlarged, it speaks either for subinvo- 
lution fibrosis or for inflammatory metritis. 

When erosions, red external os, white or yellow mucoid discharge, 
and parametritis occur in a nulliparous woman, especially in one 
who has never been curetted, they are almost certainly due to a 
mild unrecognized gonorrheal catarrh. When erosions, red ex- 
ternal os, white or yellow mucoid discharge and posterior para- 
metritis occur in a woman who has aborted or has borne a child 
or children, especially if these conditions are resistant to treat- 
ment, they too are often the result of gonorrheal infection. Every 
cervical catarrh in nulliparae or in younger multipara? should be 
considered gonorrheal unless most exhaustive examination dis- 
closes another possible etiology. 

If a woman has aborted or borne children or has been curetted, 
etc., we must, of course, take into consideration: (i) the possible 
introduction of other bacteria and (2) the retention within the 
uterus of macroscopic or microscopic fetal or decidual cells which 
cause a saprophytic fluor which discolors the cervical mucus. 
The other lesions noted in cervical catarrh, aside from erosions, 
red external os, white or yellow mucoid discharge, and posterior 
parametritis, are not so significant of gonorrhea. A distinction 
30 



466 MEDICAL GYNECOLOGY 

must be based on the presence of other lesions, the time at which 
they were acquired, and the age of the patients. A distinction 
must be made between nulliparae and multiparas. 

The additional lesions produced by chronic cervical catarrh, 
such as ovula of Naboth, metritis colli, and cervical polyps, are pro- 
duced by the action of various bacteria or cocci of a saprophytic 
type or by saprophytes which grow on the non-resistant tissues of 
subinvoluted uteri in older women or in the subinvoluted fibrotic 
uteri of women at or near the climacterium. 

In catarrh involving the outer surface of the cervix, the vaginal 
portion or portio, we observe the same changes as in colpitis. 
There are no folds, as in the vagina, and changes in the papillary 
bodies do not occur so markedly, for the papillary bodies in the 
mucous covering of the cervix are not well developed. We may 
have either a diffuse intense redness or red spotted alterations, 
looking like an eruption. There may be observed small excres- 
cences resembling pointed condylomata. 



SYMPTOMS 

The two symptoms of endocervicitis are cervical mucoid dis- 
charge and the pain due to involvement of the cellular connective 
tissue. This involvement of the cellular connective tissue is called 
parametritis. 

Parametritis. — The cervical portion of the uterus, in particular, 
is embedded in and surrounded by large amounts of connective 
tissue. The cervix enters into the upper end of the vagina at an 
angle with the latter. The position of the vagina, its relation to the 
levator ani, and its close union with the surrounding connective 
tissue, with the support furnished by the peritoneum, and by the sur- 
rounding ligaments, make the situation of the cervix a relatively 
fixed point. So long as the cervix is retained in this position and at 
this level, and so long as the uterus, its ligaments, and the parame- 
trium preserve their natural elasticity, so long will the forces of 
pressure and tension within the abdominal cavity preserve the uterus 
in its normal antenexed situation. The connective tissue about the 
cervix spreads out in the form of a six-pointed star. Each arm 
is covered by peritoneum, contains blood-vessels, muscle fibers, 



ENDOCERVICITIS OR CERVICAL CATARRH 467 

and lymphatics. Thus are formed the six ligaments which find 
their attachment to the uterus entirely or in part along the cervix or 
at the level of the internal os, the broad ligaments, of course, ex- 
tending up the fundus. The base of the broad ligaments, which is 
particularly rich in muscle fibers and lymphatics, is called the liga- 
mentum cardinale. 

An important function of the connective tissue, with its numerous 
muscle and elastic fibers, is to keep the cervix in an elevated posi- 
tion , and the elasticity of the ligaments is intended to give the uterus 
free play. As Winter says, the uterus may be pulled up to the 
symphysis, pushed toward the sacrum or up to the lateral pelvic 
wall or half-way up to the umbilicus, or the portio may be pulled 
down to the vulva, and all this without pain. When the uterus is 
pushed up or pulled down, it returns to its normal place because 
of the elasticity of its surroundings. It belongs, therefore, to the 
most movable parts of the body. 

A chronic catarrh of the cervix may mean continued lymphatic 
infection. The uterosacral ligaments and the posterior parame- 
trium are most frequently involved by the chronic catarrh. It is 
especially the uterosacral ligaments which are constantly becoming 
more inflamed through involvement of their lymphatic elements. 
After months or years they become sclerosed and shortened, 
causing backache and producing infiltration about the rectum 
and the sigmoid. In addition, there may be an invasion of the 
broad ligaments, though this invasion is generally marked in 
chronic cases, only when associated with lateral tears. This 
posterior parametritis produces a retrodisplacement of the uterus. 
(See Fig. 89.) 

Such cases of catarrh may remain always located in the cervix 
and the surrounding connective-tissue areas, never passing, so 
far as evidences go, above the internal os. Such patients may have 
children and may never suffer from uterine, tubal, or peritoneal 
annovances. A cervical gronorrheal catarrh also which does not 
extend upward after an abortion or a pregnancy, and thus permits 
of a second pregnancy, probably always remains in the cervix 
alone. Such patients finally come with a large cervix, a 
normal or large uterus, a parametritis posterior, or a retrodis- 
placement due to shortening of the uterosacral ligaments, or with 



468 MEDICAL GYNECOLOGY 

combinations of those conditions. Their main complaint is 
backache. Treatment often brings about a cure. Ofttimes 
the pain persists. They are then somewhat benefited by amputa- 
tion of the cervix and by the performance of an Alexander- Adams 
operation. They are not infrequently best relieved by a hyste- 
rectomy. We must distinguish hypertrophy of the cervix plus 
parametritis which are due to cervical catarrh from hypersecretion 
present in a cervix and uterus hypertrophied as a result of subinvo- 
lution. If the cervix alone is enlarged while the uterus is of normal 
size, this condition speaks for the former. If the cervix and uterus 
are both enlarged, we are dealing either with subinvolution fibrosis 
or with inflammatory metritis. 



DIAGNOSIS OF EROSIONS OF THE CERVIX 

Catarrh of the cervix, or endometritis cervicis, is an inflammation 
of the cervical mucosa, extending from the external to the internal 
os, in the course of which inflammatory evidences may appear on 
the outer surface of the portio. It is easier to diagnose than endo- 
metritis, because part of the mucosa can be seen and because 
there are certain changes which occur on the portio with cervical 
catarrh only. If the lips of the cervix are everted by the use of 
volsella, the cervix mucosa is seen to be red, velvety, and 
shiny. Erosions, ectropion, follicles of Naboth, metritis colli, 
polyps, are sure signs of existing or previously existing cervical 
catarrh. Erosions are due to maceration and desquamation of 
the squamous epithelium and % the covering of the denuded areas 
by cylindric ciliated epithelium which grows out from the cervival 
canal. Erosions may have a rough or furrowed surface and an 
irregular periphery. The color is a light red to a scarlet, sometimes 
.bluish-red in pregnancy. Simple erosions have a smooth even 
surface. A few follicles may be present in the circumference. 
Follicular erosions evidence many tiny follicles in the erosion or 
in areas covered by squamous epithelium or in areas of a red 
character. Papillary erosions have a surface which feels smooth, 
but is of a finely granular character due to microscopic projections. 
They bleed easily when the mucus is removed; they are sharply 
outlined and contain no follicles. Erosions are to be distinguished: 



ENDOCERVICITIS OR CERVICAL CATARRH 469 

*(i) from circumscribed reddening of the portio in colpitis, which 
latter is not concentric about the os, is not velvety, and bleeds very 
easily; (2) from a red congested cervix due to irritations produced, 
for instance, by a pessary; (3) from ulcerations of the cervix due 
to irritation and injury, as in cases of prolapse of the uterus; 
(4) from true ulcers of the cervix, which are usually syphilitic or 
tuberculous; (5) from ectropion, which means irritation and in- 
flammation of the everted lacerated cervical mucous membrane. 
Only the papillary, and rarely the follicular forms, resemble malig- 
nancy. When, the cervix is torn in labor and the lips gape, the 
cervical lining is often everted. If no inflammation is present in 
the vagina or in the cervical canal, the everted mucous membrane 
has sometimes a red appearance, but usually the epithelium under- 
goes epidermal changes and no redness is present. With inflam- 
mation the everted mucous membrane is markedly, red, is elevated, 
and takes on the appearance of an ulcer or fungus. There is 
hyperplasia of the glandular epithelium and often hypertrophy 
of the glands. In other words, we observe on the everted cervical 
lips those changes which take place within the cervical canal in 
cases of catarrhal infection. This condition is known as inflamma- 
tory ectropion. The everted mucosa is red and we see folds 
representing the arbor vitae of the cervix and also newly formed 
furrows. It looks like fresh red granulation tissue, and if it bleeds 
easily, it may suggest carcinoma. 



DIAGNOSIS OF ENDOCERVICITIS 

One of the surest evidences of the existence of infection of the 
cervix is a slight zone of inflammation about the external os. This 
zone is of a bright and sometimes a dark red color and has a shiny 
appearance. Further proof is furnished by a slight extrusion of 
the red cervical mucosa of the anterior and posterior cervical lips. 
These two changes may be present with or soon after an acute 
invasion also. In the early stages of an infection erosions are 
rarely formed. It is with the chronic catarrhal infection of the cer- 
vix that erosions take place. In the cervical catarrh of nulliparae 
with narrow external os the mucus is retained and the canal is 
dilated. In all cases of cervical catarrh, and especially if the 



470 MEDICAL GYNECOLOGY 

above evidences are absent, the secretion should be examined. 
The secretion may be clear or it may be grayish or yellow. It 
contains epithelium, leukocytes, or in more infectious stages it 
may be mixed with pus and be very yellow or green. The diagnosis 
between hypersecretion and inflammation is important. In the 
latter we find inflammatory changes in the mucosa, erosions, the 
admixture of pus, and often vaginitis. Cervical catarrh in the 
absence of these symptoms should not be diagnosed without 
anomalies in the secretion. 

Follicles of Naboth are retention cysts which occur in the fundus 
of the glands of the cervix, or in the glands of erosions. They are 
small circumscribed projections containing translucent light or 
yellow mucous. If situated deeply, they may cause thickening of 
the portio. If this thickening is associated with interglandular 
hypertrophy, it is known as follicular hypertrophy. 

Chronic induration or metritis coli, when not due to subinvolu- 
tion and not part of a general uterine hypertrophy, is a sequela of 
catarrh. The cervix becomes thick and hard and fibrous. The 
cervix may be enlarged through concealed ovula of Naboth or 
through the extension of the chronic inflammation into the connec- 
tive tissue and muscle fibers of the cervix and into the connective 
tissue immediately about the cervix. 

Extension of the inflammation into the connective tissue about 
the cervix, or into the connective tissue of the six ligaments con- 
nected with the cervix, produces parametritis. By far the most 
frequent form is the so-called parametritis posterior chronica which 
involves the uterosacral ligaments and the posterior parametrium. 

Pain in the back and limitation of mobility of the cervix are 
noted in chronic cases (Fig. 89). In newer cases the uterosacral 
ligaments feel swollen and tender on examination. Mucous 
polyps may be found in connection with chronic cervical catarrh. 
They consist of circumscribed hyperplasia of the cervical mucous 
membrane. They vary in size from a pea to an egg and, as a rule, 
have a long pedicle. They are soft and shiny, red and covered 
with mucus, and bleed very easily. The surface is generally 
tabulated and they often contain small retention cysts. They 
are generally found in multipara? after the existence of an extremely 
mild, long-continued intracervical irritation. In women near the 



ENDOCERVICITIS OR CERVICAL CATARRH 47 1 

climacterium they speak rather for a saprophytic involvement 
of cervical tissue non-resistant in character. 



TREATMENT 

Treatment of cervical catarrh should be conservative and carried 
out entirely in the vagina and not within the cervix. Our whole 
purpose is to remove from the cervical canal the causes and the 
products of the inflammation. The cervical lining is not smooth, 
but is composed of deep depressions forming an irregular surface. 
This canal is lined with high cylindric epithelium. The bacteria, 
bacilli, or cocci which are producers of the inflammation may be 
located deep down in these recesses, even if not diffusely so, or 
between the epithelial cells or underneath the epithelial cells. 

Local applications cannot destroy the bacteria in the depths 
unless we at the same time destroy the entire cervical lining. In 
my experience, local applications keep up the irritation, and if 
of a strong nature they produce hard, sclerotic changes, and the 
tendency is to send the inflammation further into the cervical 
structure and out into the surrounding connective tissue. Our 
whole purpose, then, should be devoted to gently cleaning the 
cervical canal and draining out all the products of inflammation 
in the deepest recesses, and in this way aiding nature in throwing off 
the remaining infecting bacteria. If the cervical secretion is 
extremely tenacious, only as much as can be done without injury 
should be removed by gentle sponging and cotton applicators. 
By the use of a suction bulb, as much more as possible should be 
drawn out (Figs. 12, 13). Then boroglycerin to the amount of 1 
ounce is poured into the vagina through the bivalve speculum. 
The fornices are then gently but firmly packed with one long 
strip of 6-inch wide soft gauze. This brings the glycerin into 
intimate contact with the intracervical mucosa. The long strip 
of gauze is then gently packed into the vagina and the whole is 
allowed to remain in place for twenty- four hours (Figs. 47, 88). 
As a result, a large amount of serous exudation takes place, the 
glycerin drawing out the cervical contents and acting on the deeper 
recesses as well. At the end of twenty-four hours the gauze is 
taken out and a vaginal douche is given. This treatment by 



472 MEDICAL GYNECOLOGY 

glycerin is carried out two, or better three, times each week. 
Regular examination of the cervical secretion corroborates the im- 
provement apparent to the eye, for the secretion becomes gradually 
paler in color until it finally becomes quite clear and microscopic 
examination shows almost no pus cells and only squamous cells. 
If this treatment is continued, the cervical secretion finally becomes 
clear and our purpose is accomplished without irritation of any 
form. I rarely use intracervical applications of any form, except 
perhaps once to produce an increased discharge as an aid in the 
final microscopic diagnosis. 

The erosions are treated by local applications of carbolic acid, 
followed immediately by a thorough painting of the whole cervix 
and fornix with plain tincture of iodin. Glycerin, which is used for 
its influence on the cervical lining, is of undoubted value in the cure 
of erosions, for it dehydrates and draws out from the depressions 
in the erosions the inflammatory products and the producers of 
inflammation. The choice of medicated douches which are used 
in conjunction with this treatment depends on the stage of the 
condition and on the associated bacteria found by examining the 
vaginal secretion. The three best drugs are, first, acetate of 
aluminum, i dram to the quart, because of its healing effect; 
bichlorid of mercury, i : iooo, because of its destructive action on 
associated bacteria and because of its great value in those cases 
where gonococci are found; and an astringent powder in the form 
of sulphate of zinc plus tannic acid 2 drams to the quart, which 
are of use in the later stages where hypersecretion still persists. 

Patience is needed in the treatment of cervical erosions, as their 
cure not infrequently takes several weeks. It is not sufficient to 
make local application to the external surface of the cervix. The 
associated cervical catarrh must be treated and cured. The 
best form of treatment is the application of pure carbolic acid by 
cotton applicator to the entire erosion area. The application is 
allowed to remain for only a few seconds if the erosions are super- 
ficial; but if the erosion is papillary or glandular, the carbolic 
acid must be allowed to act longer, the idea being to destroy the 
ciliated epithelium which is growing in the area normally covered 
by squamous epithelium. The application of carbolic acid is then 
immediately followed by several applications of pure tincture of 



ENDOCERVICITIS OR CERVICAL CATARRH 473 

iodin, which is applied also to the entire cervix covering and to 
the vault of the vagina. The alcohol in the iodin tincture neutra- 
lizes the further action of the carbolic acid and the iodin is applied 
for its alterative and antiseptic properties. An ounce or more of 
boroglycerin is then poured into the vagina and the vagina is packed 
with gauze, which is thoroughly packed into the fornices. The 
gauze is removed at the end of twenty-four hours and vaginaL 
douches are given twice daily consisting of the above-mentioned 
three drugs or of three to four tablespoons of pyroligneous acid 
in 2 quarts of water. The applications to the cervix of iodin are 
made three times a week, the carbolic acid being applied once or 
twice a week, according to the degree to which the ciliated epi- 
thelium has been destroyed. Unless the ciliated epithelium is 
entirely destroyed (and not too deeply at any one time, in order 
to avoid bleeding or oozing) the erosion will not heal. When 
healing takes place, the squamous epithelium is seen to gradually 
grow in from the edges. In the later stages its growth may 
be stimulated by the local application of nitrate of silver from 
1 per cent, up to 5 per cent. It may be done once or twice a week. 
The purpose of the boroglycerin treatment is to draw out the cervicaL 
mucus and to draw out the cervical inflammation from the very 
depths of the glandular recesses. When the canal becomes clearer 
and the mucus becomes colorless, the lining of the cervix may be 
gently painted with tincture of iodin or with 1 per cent, nitrate of 
silver. 

In the treatment of erosions stubborn cases must be painted 
with 50 per cent, solution of chlorid of zinc. In other cases the 
erosion must be painted with pure pyroligneous acid or with pure 
formalin followed by the boroglycerin treatment. The cervical 
canal in certain stubborn cases is gently cleared of its mucus and 
is painted with 2 to 5 per cent, silver or with 10 per cent, solution 
of chlorid of zinc. In my experience the avoiding of intracervical. 
treatment is in most cases followed by good healing results and no 
induration, inflammation, or stricture of the canal takes place. 

If follicles are present, they should be opened, the mucus squeezed 
out, and the little recess should then be touched with carbolic acid, 
followed by iodin. 

A distinction must be always made between erosions and ectropion.. 



474 MEDICAL GYNECOLOGY 

Ectropion simply represents the everted mucous membrane of the 
cervix, when deep lateral tears are present. Hence ectropion is found 
only in women who have borne children, while erosions are present 
in nulliparae or multiparae, most frequently in the former. In 
cases with marked ectropion or in erosions of the cervix associated 
with diffuse hypertrophy, especially where the cervix is filled with 
dilated follicles, high amputation of the cervix gives an immediate 
and satisfactory result. 

Local applications to the lining of the cervix which exert a 
superficial action are of no utility for destroying the causes, and 
certainly of no value from a healing standpoint, so long as a mucus 
plug obstructs the cervix and bacteria are still present in the glandular 
recesses. If for no other reason, routine intracervical treatment is 
contraindicated in such conditions. Local applications to the cer- 
vical lining which have a deep cauterizing action often only serve to 
keep up the inflammation, to send it out into the cervical wall or into 
the surrounding connective tissue or further up into the uterus and 
often higher still. The element which frequently sends the cervi- 
cal infection (if gonorrheal) further up is parturition, in which 
case we have, as a rule, a late infection. Abortion is a frequent 
factor in sending an infection further up. A curetting is of still 
greater danger in causing an ascending extension of the original 
cervical condition. Ectopic gestation occurs more frequently in 
women who have borne children than in women pregnant for the 
first time. This is due to the fact that parturition often results 
in an ascending infection which mildly involves the tube. If the 
involvement of the tube is sufficiently marked to cause closure of 
the external ostia, these patients are permanently sterile. If, 
however, the cocci are less virulent the tubal ostia are not closed, 
the infection in the tubes is not so extensive as to prevent regenera- 
tion of active ciliated epithelium, and the sterility is only tempo- 
rary, though it may last for years. Women are rarely treated for 
secondary sterility, and in such cases no additional harm is done 
by intracervical or intrauterine applications. In other words, no 
increase of the tubal affection is produced. Therefore the tubal 
affection in such uniparous women is often relatively slight, and 
in them or even in severer cases goes on to healing or else is almost 
healed at the time when the ectopic gestation occurs. Nulliparae, 



ENDOCERVICITIS OR CERVICAL CATARRH 475 

on the other hand, are frequently treated for sterility. The cervix 
is dilated, the sound is used, curetting is done, intrauterine applica- 
tions are made, the mucosa is constantly irritated, inflammatory 
extension upward is constantly stimulated, and as a result the tubes 
grow progressively worse and have no chance to heal even partly. 
Therefore either the tube-ends become closed or the ciliated epithe- 
lium in the tubes is in such a state that no ovum is drawn into the 
lumen and therefore ectopic gestation in them is much less frequent. 
Many nulliparae have a specific (gonorrheal) cervical catarrh 
without any knowledge on their part, but become pregnant before 
sufficient harm is done to both tubes to prevent the ovum from 
entering the uterus. 



ENDOMETRITIS 

A healthy endometrium is essential to the functions of normal 
menstruation and of pregnancy. The endometrium in its structure 
is very much like lymphatic tissue. It is lined on its inner surface 
by a single row of epithelial cells and contains in its lymphatic 
stroma glands whose epithelial lining is in direct continuity with 
the single layer of epithelium which lines the endometrium. This 
endometrium undergoes, from the age of thirteen on, a periodic 
monthly stimulation by the ovarian secretion which results in a 
periodic hypertrophy of all the constituent elements and in con- 
gestion of the blood-vessels and capillaries. The purpose of this 
periodic stimulation is to furnish a proper basis in which an ovum, 
if fecundated, may grow. The endometrium naturally undergoes 
alteration in connection with, and in consequence of, its intimate 
relation to the local processes involved in menstruation and in 
pregnancy. At a later period, at the climacteric age, the endo- 
metrium, through atrophy of the ovaries, undergoes regressive 
steps, the course of which may be changed by the injuries which 
it has sustained during the various periods of life. 

The uterus with its lining is at all times under the direct trophic 
control of the ovaries and their secretion. Normal ovaries are 
necessary to the production of a uterus and endometrium capable 
of performing the regular function of menstruation and of furnish- 
ing a nest for the development of a fecundated ovum. The endo- 
metrium through direct involvement of its own elements, through 
interference with its blood-supply, through involvement of its 
trophic centers, the ovaries, may at various periods of the feminine 
life undergo alteration in its character and structure. The endo- 
metrium is liable to changes during childhood. It is subject to 
injuries as a result of local or constitutional infectious diseases 
at any period. It is subject to injuries in connection with pregnancy 
and undergoes alteration on the presence of new- growths. 

Etiology. — In childhood we are concerned with an etiologic 

476 



ENDOMETRITIS 477 

factor included under the head of the infectious diseases of child- 
hood, such as measles, scarlatina, mumps, typhoid and diphtheria, 
etc. The diseases not infrequently produce lesions of varying 
degrees in the ovaries themselves or in the lining of the uterus. 
These alterations may be temporary or permanent. If permanent, 
they begin to manifest symptoms when the ovaries and endome- 
trium enter into the menstrual phase. We therefore may have 
early changes in the endometrium due to direct involvement of 
the uterine lining itself in the course of these infectious diseases of 
childhood, or else we may have secondary changes in the endome- 
trium due to impairment of function in the ovaries themselves. 
These latter lesions are trophic in their nature. 

In children we are further concerned with a bacterial infection 
of the genital tract by the gonococcus, which manifests itself, as a 
rule, in the form of an acute vulvovaginitis. This disease is very 
difficult to cure, because the gonococci thrive exceedingly well on 
the genital epithelium of the child. It is, however, not generally 
recognized that in many cases the gonococci produce an infection 
of the cervix, and that factor plays an important part in keeping 
up the inflammation in the vagina and vulva. In addition, in 
not a few instances, even when no symptoms are present, the uterine 
lining itself is involved. In cases in which the inflammation is 
present in the endometrium it may extend up into the tubes and 
out into the peritoneum. While not recognized at the present 
time, a gonorrheal peritonitis in children is by no means infre- 
quent, and the probability is that the majority of these cases are 
diagnosed as appendicitis. It is certain that this etiology bears 
an important relation in such cases to the subsequent condition 
of the endometrium, either primarily, through the direct involve- 
ment of the uterine lining, or else through some involvement of its 
trophic centers, the ovaries. 

When the menstrual function begins, existing alterations in the 
structure of the endometrium considerably influence the course of 
menstruation. Other infectious diseases, such as typhoid fever, 
may later come into play. Such an etiology may affect the endo- 
metrium primarily and directly, or secondarily through the in- 
volvement of the ovaries. At this period, and at any other subse- 
quent stage, congestions in the genital tract certainly have an 



478 MEDICAL GYNECOLOGY 

important bearing on the character and growth of the endometrium. 
Among the causes of pelvic congestion a place of importance must 
be given to onanie or masturbation. 

A further important etiologic factor in adult life, and one which 
is inflammatory in its character, is infection by the gonococcus y 
which infection may be acute or subacute in its nature. In fact, a 
very large proportion of gonorrheal infections of the endometrium 
are of so mild a character as to be scarcely recognized until asso- 
ciated lesions call attention to their existence. Here, too, involve- 
ment is primary and direct, but may be complicated by involvement 
of the trophic function of the ovaries. 

An element of importance with regard to the endometrium is 
concerned with the period of the female life in which pregnancy 
may occur, and here we must consider interruptions of pregnancy 
in the form of abortion, ectopic gestation, labor at full term, etc 
The changes to which the endometrium is then liable are due to the 
relation which the endometrium bears to the growing ovum. 
Alterations in the character of the endometrium may be due to 
the fact that cells of the trophoblast or chorionic cells or placental 
structures remain and prevent a return to the normal on the part 
of the endometrium. Even if no cells of the ovum be left behind, 
a complete restoration to the normal implies a disappearance of the 
decidua and a substitution by normal endometrium. However, 
decidual cells or the entire decidual membrane may remain or 
the mucosa may return only partially to the normal. Another 
factor of importance in connection with pregnancy is the failure 
on the part of the uterus to return to its normal state. We refer 
here to the condition known as subinvolution, wherein congestion 
and hyperemia play an important part in altering the form and 
structure of the uterine lining. 

Various infections may occur in connection with pregnancy,, 
which infections are generally classed under the title of puerperal 
infection. This is of two forms: (i) Puerperal infection may be 
due to bacteria and bacilli introduced from without by examination 
or intrauterine manipulation, or (2) it maybe due to bacteria present 
before pregnancy, which bacteria are then frequently the gonococci. 
We are concerned in these infections mainly with streptococci, 
staphylococci, the bacterium coli, the gonococcus, and saprophytic 
bacteria and cocci. 



ENDOMETRITIS 479 

Diseases about the uterus have a bearing in altering the appear- 
ance or function of the endometrium, either through the pressure 
which they exert on the vessels running into the uterus or because 
these diseases are inflammatory in their nature. Since most of the 
inflammatory conditions about the uterus are the result of infection 
extending through the uterus, we are really concerned with altera- 
tions in the endometrium due to the same causes as produce the 
periuterine inflammation, or else we are concerned with alterations 
in the endometrium resulting from inflammatory involvement of 
the periuterine vessels and of the ovaries. Among the bacterial 
infections to which the uterus is liable must be mentioned that by 
the tubercle bacillus, which, while rare, does occur in the form 
of an ascending infection from the cervix, or in most instances in 
the form of a descending infection, subsequent to involvement of 
the peritoneum. 

Aside from these changes in the endometrium new-growths have 
an important relation to the lining of the uterus. It is natural 
to expect a deviation from the normal with sarcoma or carcinoma, 
but as these two conditions have symptoms of their own, the altera- 
tion in the character of the endometrium is of secondary importance. 
With rhyomata, however, the question is different, for we are 
concerned here either with small unrecognized tumors or with 
larger recognized tumors. When myomata are situated in the 
uterine wall, or particularly when they are situated under the 
mucous membrane, it is only natural that their presence and the 
pressure which they exert and the congestion which they produce, 
together with the zone of hyperemia about their periphery, should 
produce alterations in the character and structure of the uterine 
lining. 

At a still later period, at the time of the climacterium, the uterine 
lining is supposed to undergo regressive changes. Here too 
variations in this process may take place, sometimes depending on 
the alteration produced in earlier years, at other times depending 
on the changes which are going on in the ovary. Many local 
changes, therefore, are dependent on the trophic action of the 
ovaries ; hence the various deviations from the normal which are so 
frequently found at the climacteric period. 

Non-inflammatory Alterations of the Endometrium.— The 



480 MEDICAL GYNECOLOGY 

uterine lining may undergo modifications by any new-growth 
involving the uterine structure, such as carcinoma, sarcoma, and 
fibroma. With carcinoma and sarcoma we are concerned with 
affections which have a specific appearance and symptoms of their 
own. Fibroids, whether single or multiple, whether large or small, 
especially if situated in the uterine wall and near the mucous 
membrane, produce changes especially in the glands of the endo- 
metrium. Though this condition with large tumors is of secon- 
dary importance, yet the associated hyperplastic changes due to the 
presence of fibroids are called endometritis, but it can readily be 
seen that inflammation plays no part in causing this change. 
When a pregnancy has existed in a tube, the uterine lining under- 
goes change to decidual tissue. During the various stages of ectopic 
gestation this decidual lining may be thrown off, may retrograde 
and return to the normal state, or it may remain more or less sub- 
involuted. This may leave a hypertrophic uterine lining which 
involves the glands also, and which is called endometritis, but, 
again, is not inflammatory in etiology. With a pregnancy inter- 
rupted at any stage, that is, with abortion, we may have a failure 
on the part of the endometrium or decidua to return to the normal. 
Either the decidua is retained in whole or in part, or else it does 
not return entirely to the normal or else microscopic or macro- 
scopic remains of chorionic villi are retained. This may produce 
a form of so-called hypertrophic endometritis involving the glands 
and interstitial cells too, but is likewise non-inflammatory in its 
causation. 

In labor occurring at full term the uterine lining is thrown off, 
leaving only the deeper glandular areas in place for the purpose of 
restoring a normal endometrium. Here, again, the decidua may 
not be cast off as it should be. There may be a retention of macro- 
scopic or microscopic chorionic cells or placental structures, and a 
condition also called endometritis results, which is not inflamma- 
tory in its nature. Even if in all of these pregnant states the 
decidua is cast off entirely, and even if chorionic or placental cells do 
not remain, a failure of involution on the part of the uterus may 
keep up a persistent state of hyperemia which prevents the growth 
of a normal endometrium and frequently produces a hypertrophy 
or overgrowth, or also a hyperplasia involving especially the glands. 



ENDOMETRITIS 48 1 

This, again, is a non-inflammatory "endometritis." Retroflexions 
of the uterus, especially post-pa rtum displacements of the uterus 
associated with descent, and often normally situated uteri, especially 
after labor or abortion, are often accompanied by congestions which 
prevent the endometrium from remaining in a perfectly normal 
form. Here, again, we are concerned with a non-inflammatory 
"endometritis," hypertrophic and hyperplastic in character. The 
same disturbances may be evidenced in pathologic cardiac and 
constitutional affections, with which congestions and abnormal 
blood-supply in the pelvis and uterus are supposedly associated. 
General subinvolution after labor implies a state of systemic in- 
elasticity and unevenly distributed blood-supply. Here all the 
abdominal and pelvic structures are affected by venous congestion 
and stasis. The ovaries, perhaps, in some cases exert an undue 
and abnormal stimulation upon the endometrium, produce excessive 
hyperemia and congestion, and eventually aid in the formation of 
an overgrowth of the endometrium. Ovaries involved by inflam- 
matory or degenerative processes, as a rule, under-stimulate the 
endometrium, but at the same time fail to exert a normal trophic 
action on the uterine muscle. As a result fibrotic and sclerotic 
changes occur in the muscle and elastic fibers of the uterine wall, 
and arteriosclerotic involvement of the blood-vessels and capillaries 
takes place. Such alterations, if associated with circulatory 
disturbances in the uterus and endometrium, may lead to hyper- 
trophy rather than atrophy. 

Inflammatory Endometritis. — Now as regards the inflamma- 
tory form which really justifies the name of endometritis, and 
which is, almost in all instances, at least interstitial in its micro- 
scopic characteristics, we are concerned with the action of bacteria. 
The evidences are those present with inflammation in any mucous 
membrane. Often enough the process is mild or subacute or 
chronic, and for that reason simply "catarrhal" in its manifesta- 
tion. 

As mentioned above, changes in the endometrium may often be 
referred back to the inflammatory or necrotic alterations in the 
uterus complicating the infectious diseases of childhood or to infec- 
tion by the gonococcus at the childhood stage. 

Bacteria, bacilli, or cocci and their irritations may be present 
31 



482 MEDICAL GYNECOLOGY 

in a nulliparous uterus or in a uterus in which at one or more times a 
pregnancy took place. In the cases of pregnancy, whether it end 
in abortion or at full term, we are concerned with the so-called 
septic or puerperal infections. Here we are dealing with strepto- 
cocci, staphylococci, in some instances with bacterium coli, and 
in many cases with gonococci, or else we are dealing with sapro- 
phytic bacteria which grow on dead tissue only and which cannot 
survive in the living endometrium itself. These saprophytic 
bacteria may produce changes in the uterine cavity if placenta or 
membrane or other products of conception are present, but once 
these are removed the saprophytic bacteria disappear. On the 
other hand, the streptococci, staphylococci, and bacterium coli 
grow on the actual structures of the uterus and produce an endo- 
metritis or a metritis, or any or all of the various inflammations 
usually associated under the heading of post-partum infection. In 
addition to these, we are concerned in a very large number of cases 
with the gonococcus. The gonococcus, when present before a 
pregnancy, or when introduced after conception has taken place, 
concerns itself primarily with the uterine lining and the uterine 
wall, and often enough with all the other periuterine structures, 
and plays a very important part in the production of endometritis. 
If, however, we consider cases in which pregnancy has never 
occurred, the streptococcus, the staphylococcus, or the bacterium 
coli find their way into the uterus only by infection during operation 
or intrauterine manipulation. Therefore an inflammatory endo- 
metritis produced by these invaders presupposes some intrauterine 
manipulation. While this may occur, the vast majority of cases 
of inflammatory endometritis in nulliparae are due to gonococci. 
The gonococcus may produce an inflammation in the uterine lining 
which is acute or subacute. The gonococcus has the characteristic 
in most cases of being superficial in its growth and exercising its 
energies mainly on the mucous membrane, but in a goodly propor- 
tion of cases its action is not alone superficial, but deep, involving 
the uterine wall to varying degrees and extending out into the 
lymphatic connective tissue. Hence, the great variations in the 
course of gonorrheal infections are due to the fact that the infection 
is either acute or subacute, superficial or deep. Many of the 
symptoms generally associated with an endometritis gonorrheal 



ENDOMETRITIS 483 

in its nature are not so much due to the endometritis as to the 
associated metritis. 

Associated Changes in the Uterine Wall. — A point of im- 
portance is the necessity of considering the affections of the endo- 
metrium in conjunction with changes in the structure of the uterine 
wall. If we are dealing with an endometritis inflammatory in its 
character, we must consider that the same bacteria or cocci may, 
and probably do, involve the uterine wall, producing changes 
there in the character, amount, and structure of the component 
elements, and that this alteration in the function of the uterine 
wall has a bearing on the symptoms supposedly or actually as- 
sociated with the involvement of the endometrium alone. On 
the other hand, changes in the ovarian trophic center, or such 
changes as are associated with pregnancy in the tube or uterus, 
may likewise produce alterations in the uterine wall. The im- 
portant changes in the uterine wall with a non-inflammatory cause 
are those changes known as subinvolution, which means hyper- 
trophic and fibrotic alteration in the uterine wall with consequent 
modifications of the symptoms supposedly or actually associated 
with the alteration of the uterine lining. 

With any of the non- inflammatory causes mentioned above 
there may be combined an inflammatory etiology. An inflamma- 
tion may be present before or may be acquired during or after the 
pregnant state. This causes a mixed condition, that is, a com- 
bination of the inflammatory form of endometritis and the non- 
inflammatory forms mentioned above. Therefore, to repeat again, 
endometritis may be inflammatory, non-inflammatory, or a com- 
bination of the two. 

Interstitial and Glandular Changes. — The term endome- 
tritis is generally used to include all these alterations of the endo- 
metrium which are not malignant or which do not practically or 
really form a new-growth. Under the heading endometritis are 
usually grouped those affections of the mucous membrane of the 
uterus in which the 'microscope shows changes in the structure of 
the essential component elements. The changes represent differ- 
ences either in the character or in the amount of the elements com- 
posing the endometrium. Reference is usually made (i) to altera- 
tions in the stroma or interstitial round- celled connective-tissue 



484 MEDICAL GYNECOLOGY 

basis of the endometrium, or (2) to changes in the glands situated 
in the stroma, or (3) to a combination of the two. It is customary 
to speak (1) of interstitial endometritis which affects the connec- 
tive-tissue stroma in character and amount, (2) of a glandular 
endometritis which affects the glands in size, character, and number, 
and (3) of a combination of the two. It was said that a certain 
proportion of the cases of endometritis are inflammatory in etiology. 
A large number, however, are not. An attempt has been made to 
consider the interstitial form as inflammatory and the glandular as 
non- inflammatory. Microscopic evidences in the hands of the 
many observers have shown glandular changes to be also present 
with inflammatory causes, so that an exact line of division does 
not exist. 

Even though this be so, it is true that a very large number of 
cases of purely "glandular endometritis" are not to be referred to 
the irritative action of bacilli and bacteria, but are due to the non- 
inflammatory causes mentioned above. Inflammatory cases, 
however, always show interstitial endometritis. Interstitial endo- 
metritis is always inflammatory. If we concern ourselves, then, 
with those numerous cases in which both glandular and intersti- 
tial changes are present, we come to these facts. The lining of 
the uterus is at all times under the trophic control of the ovarian 
secretion. The endometrium undergoes special periodic stimu- 
lation at the menstrual period in the form of hypertrophy of all 
the elements. It undergoes still further changes during pregnancy, 
either uterine or tubal, in the form of decidual reaction. In the 
case of uterine gestation the endometrium is invaded by tropho- 
blast cells of the ovum and by chorionic villi. Alteration of the 
ovarian secretion, whether subsequent to the presence of ectopic 
gestation or to the presence of an ovum in the uterus, often results 
in or is followed by permanent changes in the form and character 
of the uterine lining. These changes not being inflammatory, are 
not interstitial in their character, but glandular, hypertrophic, and 
hyperplastic. If, however, with any of these non-inflammatory 
causes an inflammatory etiology is also present, then we get, in 
addition to the glandular change, an interstitial alteration, and it 
is probably this fact which makes the combination of the two so 
frequent. In many of these cases we are dealing with an inflam- 



ENDOMETRITIS 485 

matory and a non-inflammatory etiology, while in other cases it is 
probable that the inflammatory interstitial changes cause circu- 
latory and irritative alterations which also involve the glands. In 
other words, w T e may have: (i) an inflammatory interstitial change 
superimposed upon an existing glandular non-inflammatory altera- 
tion; (2) we may have associated glandular changes resulting 
from the congestion and hyperemia consequent upon the presence 
of interstitial inflammation in or about the uterus. If any in- 
flammation of the uterus involves the ovaries, a glandular trophic 
condition may be added to the local inflammatory. If the wall of 
the uterus is affected by inflammatory invasion, disturbances in 
the form of congestion take place, with resulting hypertrophic 
hyperplastic glandular growth, so that even though inflammation is 
responsible in many cases for glandular alterations in the endo- 
metrium, they are really secondary in their nature, and are due 
either to the trophic involvement of the ovaries, or to the changes 
consequent on congestion and hyperemia. In other words, they 
are, strictly speaking, not the immediate result of the inflammatory 
invasion itself. 

Therefore, for all practical purposes it would be well to speak 
of the interstitial form as inflammatory, the entirely glandular form 
as due to non-inflammatory causes, and the combined glandular 
and interstitial form as due to both causes, with the inflammatory 
interstitial change as the important involvement. 

In considering the various direct local disturbances which may 
take place in the endometrium we see that we are concerned (i) 
with causes inflammatory in their nature, (2) with causes which 
are not inflammatory. 

Endometritis may therefore be considered under these two head- 
ings. Under the inflammatory forms we are concerned with acute 
infections of the endometrium which are due to puerperal infection 
and to the gonococcus. We are further concerned w T ith the local 
changes occurring in connection with constitutional diseases, the 
infectious diseases of childhood, especially scarlatina. The sub- 
acute purely local inflammations of the endometrium are in al- 
most all instances due to gonorrheal infection. Inflammatory 
involvement of the endometrium may be either superficial or deep ; 
it may be diffuse or circumscribed. It may exist as a simple endo- 



486 MEDICAL GYNECOLOGY 

metritis without involvement of the uterine wall, or may exist in 
conjunction with an involvement of the uterine wall. An inflam- 
matory involvement of the endometrium may exist without ex- 
tension into the tubes, peritoneum, or periuterine structures, or 
it may exist in conjunction with these conditions. All these 
variations of superficial infection, deep infection, diffuse or cir- 
cumscribed involvement, simple endometritis, or endometritis 
with involvement of the uterine wall may be present with either 
the acute or subacute forms. 

" Endometritis " from the Standpoint of Microscopic 
Findings. — Endometritis should be considered next from the 
standpoint of microscopic findings, (a) An acute inflammation 
of the endometrium is interstitial in its character. In the chronic 
form and in acute recrudescences there are only circumscribed 
groups of round-celled infiltration. As a result of the increase 
of small round cells there is thickening of the entire mucous 
membrane, there is an increased blood-supply, and the endome- 
trium looks red. There is a growth of the small round stroma 
cells. The round cells which constitute the stroma of the endome- 
trium are increased in number. They consist of a round nucleus 
which fills out the entire cell so that almost no protoplasm is evi- 
dent. The glands in the endometrium are separated and pushed 
apart by the increased interglandular tissue, and for that reason 
seem diminished in number. In addition, there is infiltration by 
round cells, such as is usually observed with any inflammation. 
In interstitial endometritis we have all the changes characteristic 
of inflammation. The interstitial tissue is infiltrated with small 
cells in proportion to the severity of the inflammation. The round 
cells completely replace the original cells of the interstitial tissue 
in certain areas, so that gland sections are absolutely surrounded 
by small-celled infiltrations. The epithelial cells of the glands 
proliferate in certain areas as a result of the increased blood-supply. 
The small round cells become larger and epithelioid in form through 
the increased nutrition due to the newly formed vessels present 
with inflammation. 

There is another interstitial involvement of the endometrium, 
which, however, is exudative in form, and which clinically mani- 
fests its presence by the existence of a sensitive endometrium and 



ENDOMETRITIS 487 

by the symptom of dysmenorrhea. There is a sero-albuminous 
exudate between the stroma cells which looks like a finely dotted 
mass which pushes the cells apart. There are also scattered 
areas of round-celled infiltration and the glands are compressed. 
The exudate is irregularly distributed and in some parts cells are 
close together and in other parts cells are pushed apart. Although 
not generally considered as inflammatory in etiology, some cases, 
if not all, are probably to be referred to this heading. 

If there is no restoration to the normal after an acute interstitial 
inflammatory involvement of the endometrium, there results what 
is known as a chronic interstitial endometritis. The epithelial 
cells become fusiform and stellate and form fibers. Spindle cells 
are then present in place of the round original cells. The round 
cells are mixed in with the spindle cells and the uterine lining has 
a fibrous look. A further stage of this condition results in atrophy 
or cirrhosis of the endometrium. The endometrium becomes 
thin, its surface is irregular, there is an irregular line of demarca- 
tion from the muscularis, and the vessels are dilated and thickened. 
Inflammatory recrudescences are evidenced by the presence of 
new round-celled infiltration among the spindle cells. Such cases 
are helped but little by curetting, and by this operation very little 
membrane is obtained because of this atrophic change. The 
glands are compressed and atrophic. The resulting stage forms 
what is known as atrophic endometritis. 

An interstitial endometritis often results in an irregular picture 
if the glands are compressed and if recurrent attacks produce 
sclerotic changes in the stroma. Just as in cirrhosis of the liver 
there is compression, so the interstitial tissue compresses the glands. 
They become dilated or cystic and contain cell detritus. These 
dilated glands, in turn, compress the stroma so that dilatation or 
ectasia of the glands results. The presence of cysts combined 
with the presence of spindle cells speaks for a chronic inflammatory 
process. 

(b) In discussing non-inflammatory involvement of the endome- 
trium we are concerned mainly with changes produced by abortion, 
by the retention of decidua, by subinvolution of the uterus, by 
displacements of the uterus, by the presence of myomata, or by 
trophic changes resulting from involvement of the ovaries. That 



488 MEDICAL GYNECOLOGY 

a special microscopic appearance should be observed in the non- 
inflammatory cases is to be expected. 

An "endometritis" resulting from such an etiology is non-in- 
flammatory, hypertrophic, hyperplastic, and glandular in its 
nature. There is an increased growth of the epithelial cells. 
There are papillary elevations of the surface epithelium and the 
surface of the uterine lining is wave-like. The mucosa becomes 
thicker. The glands are enlarged and dilated, and for that reason 
come closer together. When the glands are still further increased 
through epithelial growth, they become twisted and screw-like in 
shape. Through the tendency of the increased extent of epithelial 
surface to accommodate or place the increased epithelial elements 
there takes place a papillary appearance in the glands, which on 
section gives them a saw-like appearance. Glands become dilated 
by the increased secretion and may become cystic. The whole 
endometrium is thickened. Hyperplasia may also take place. 
New glands are formed from the surface epithelium and branches 
are given off from glands, either by eversion or by inversion. 

Glands increase by a process going on in the gland lumina and 
called inversion, or by a process taking place outside of the glands 
and called eversion. Hypertrophy means an increase in the size 
of the glands. Hyperplasia means an increase in the number of 
glands produced by division or by glands given off from the main 
glands with an increased number of lumina. A still further change 
is the growth of the glands into the muscularis of the uterus. 
This latter condition readily recurs after curetting or treatment, 
and spontaneous cure at the menopause age seldom takes place 
(Winter). 

(c) In a combination of the interstitial and glandular form we 
find the glands enlarged and papillary, but instead of being near 
together, they are pushed further apart by the increased inter- 
stitial tissue. Evidences of interstitial inflammation are present. 
If in connection with interstitial endometritis the glands become 
wider, and if papillary epithelial projections are present in the 
glands, we have an endometritis interstitialis and glandularis. If 
in glandular endometritis with enlarged glands and saw-like 
glands the glands are not close together and there is an interstitial 
change, we have endometritis glandularis and interstitialis. If it 



ENDOMETRITIS 489 

is hard to decide whether there is more glandular or interstitial 
change, the term diffusa is used. 

Endometritis fungosa defines a change in the endometrium in 
which the mucosa projects above the surface like a fungus. Some- 
times there is more of the interstitial change, sometimes more of 
the glandular. At any rate it signifies a hyperplasia as the basic 
alteration, and refers particularly to the glands. 

In some cases of myoma the surface layers show interstitial 
changes while the deeper layers show a glandular change. 

In the hemorrhagic form of endometritis the microscope shows 
an endometrium which looks like menstrual membrane. In 
some cases the appearance is so characteristic as to be termed 
apoplexy. In the above various conditions involving changes 
in the endometrium the vessels may show no change; they may 
be dilated, there may be hemorrhage in the tissues, the walls of 
the capillaries may be thickened, the entire endometrium may 
look like the endometrium of menstruation, and, as said before, 
so much blood may be present in the tissue that it deserves the 
name of apoplexy. 

Characteristic Differences under the Microscope. — In acute inter- 
stitial endometritis there is an increase of the small round cells. 
In the subacute or chronic form spindle-shaped cells predominate. 
In the dysmenorrheic form we find in the mucous membrane round, 
cells which possess a protoplasm and a small sharp nucleus, and 
the cells seem to lie free in the interstitial and exudative tissue. 
Spindle cells and larger cells with protoplasm are also present and 
the entire picture resembles that of decidua. In decidua, however, 
all the cells are changed. In the interstitial and in the exudative 
forms the change is not uniform. In addition the intercellular 
substance in decidua is homogeneous and but little fibered, whereas, 
in exudative endometritis it is finely dotted and fibered. Presence 
of ectatic glands, cysts, and bands of spindle cells speaks for chronic 
inflammation. In glandular endometritis with myoma the stroma 
cells are much enlarged and resemble decidua or sarcoma, but a 
distinction exists, for in decidua the nucleus stains poorly and 
there is exudate between the cells. In endometritis glandularis 
the epithelium is often larger and often higher, and resembles 
cervical epithelium, but the nucleus is always central. Hyper- 



49° MEDICAL GYNECOLOGY 

trophy of glands does not lead to much thickening of mucosa. 
Hyperplasia leads to thickening of mucosa and is most marked in 
fungoid endometritis, which is hyperplastic, glandular, ectatic. 

At the menopause the endometrium becomes thin, the glands 
become smaller, the stroma undergoes atrophic changes. Small 
cysts may be present, for the epithelium is pale and becomes 
loosened from its wall, and finally spaces are present which are 
filled with cell detritus. On absorption of this cell detritus we 
may have only cell spaces. This normal change, occurring at the 
climacterium, may in some instances lead to the healing of a gland- 
ular hyperplastic endometritis. 



SYMPTOMS 

The symptoms associated with involvement of the endometrium 
are subjective or objective. The subjective symptoms associated 
with circulatory, nutritional, or inflammatory involvements of the 
endometrium are bleeding, pain, fluor, or combinations of these. 

Subjective Signs. — For clinical reasons, therefore, endome- 
tritis has often been divided into endometritis hemorrhagica, endo- 
metritis dysmenorrhceica, and endometritis catarrhalis. Inas- 
much as bleeding and pain may be due to other conditions than 
endometritis, and as fluor may come from the vagina or cervix, 
errors are readily made by the use of these terms which are based 
purely on symptoms. On the other hand, certain forms of endo- 
metritis which have typical objective characteristics are called 
endometritis gonorrhceica when gonococci are found on exami- 
nation, endometritis exfoliativa when endometrial membrane is 
thrown off at menstruation, and endometritis fungosa when ex- 
amination by the sound shows an overgrown fungoid lining in 
the uterus. For therapeutic reasons it is better to diagnose changes 
as either non-inflammatory or inflammatory, and to pay additional 
attention to objective symptoms in the examination of the uterus 
and its lining. 

An obstacle to the proper understanding of the question of endo- 
metritis is due to the fact that to many endometritis always im- 
plies hemorrhage. In certain forms bleeding is a symptom. 
When menorrhagia is the only symptom corroboration of the diag- 



ENDOMETRITIS 49 1 

nosis of endometritis must be gained from an objective examination 
and all other various possible causes of intrauterine bleeding must 
be taken into consideration and excluded. The bleeding which is 
a symptom of endometritis is generally a menorrhagia. Menor- 
rhagia is much more frequent than metrorrhagia. It is noted that 
menstruation gradually comes on more profusely and the bleed- 
ing lasts for progressively longer periods, often for even ten or 
twelve days. Bleeding may occur, then, every two or three weeks, 
and at times may be intermenstrual, especially after exertion. 
Patients may bleed severely, the blood simply flowing away, and 
large pieces may be lost. In many instances the patients recover 
slowly from the loss of blood and a state of chronic anemia not 
infrequently results. This menstrual bleeding implies conditions 
which increase and lengthen the congestive hyperemia, or condi- 
tions which do not cut the hyperemia short. Bleeding is most fre- 
quent with the glandular hyperplastic fungoid involvement of the 
endometrium. Such a non-inflammatory change is due to, and 
is associated with, congestion and hyperemia, and bleeding readily 
occurs. Exudation of blood into the mucosa may be so marked 
as to deserve the name of apoplexy. Associated with the changed 
endometrium are often subinvolution of the uterine wall, or de- 
generative or atonic changes in the uterine muscle, and fibrotic 
alterations of the uterine wall. These changes imply altered 
muscle and elastic fibers and a lack of uterine contractility or uterine 
atony. Such uteri fail to cut the menstrual hyperemia short and 
the overgrown mucosa lacks elasticity and control over the capil- 
laries. 

Bleeding may further occur with acute inflammatory infection of 
the tubes, of the parametrium, or of the perimetrium. This may 
mean either marked uterine hyperemia or a uterine inflammatory 
endometritis with hyperemia. The greater and the more intense 
the hemorrhage and the longer the hemorrhage lasts after inflam- 
mation about the uterus subsides, the more does the bleeding 
speak for an actual inflammatory involvement of the endometrium, 
and this is generally associated with involvement of the uterine 
wall and is accompanied by congestion produced by the peri- 
uterine inflammation or by periuterine exudates. Bleeding which 
occurs with chronic inflammation of the endometrium is usually 



492 MEDICAL GYNECOLOGY 

due to involvement of the uterine wall, or to congestions produced 
by periuterine inflammation and exudates. Here, again, we have 
conditions which increase and lengthen menstrual hyperemia. 
Here, again, a lack of contractility and elastic power in the uterine 
wall furnishes conditions which do not cut the hyperemia short. 

In the non-inflammatory hyperplastic forms of endometrial 
involvement, if bleeding is excessive, pain may appear with the 
first outpour of blood, and is then due to the fact that the blood is 
poured out in large amounts and becomes clotted, so that marked 
contraction of the uterus is necessary to force it through the cer- 
vical canal. Here pain occurs with the expulsion of each clot. 
Through overgrowth of the mucosa at the internal os, or through 
inflammatory swelling of the cervico-uterine mucosa at the internal 
os, an acquired obstruction to the outflow of blood may cause dys- 
menorrhea, but acquired uterine pain is usually a symptom associ- 
ated with an inflammatory involvement of the endometrium or of 
the uterine wall. It may begin eight days before menstruation, when 
the menstrual congestion first takes place. There is a feeling of 
pressure in the pelvis, a feeling of fullness and weight, a desire to 
go to stool, and a frequent desire for micturition ; there is pain in 
the back and legs and the consciousness of the existence of a uterus. 
This group of symptoms is very frequently noted with those in- 
volvements of the endometrium which are inflammatory in their 
nature. The important characteristic of these pains is that they 
occur also at the menstrual period, or only at the menstrual period. 

Uterine pain has the character of labor pains. There is also a 
sensation of pressure and bearing down. Pain is generally felt 
in the uterus, but not infrequently in the region of the umbilicus or 
sometimes near the ribs. The pain is frequently felt in the uterus 
a day or two before menstruation. It is due to contraction tak- 
ing place in a uterus whose endometrium or wall is inflamed. 
The pains may occur between menstrual periods, and are then 
generally due to accumulation of secretion within the uterus. A 
point which speaks in favor of an inflammatory etiology is that this 
uterine pain first comes on after marriage. Any uterine dysmenorrhea 
which becomes worse after marriage, or which is first acquired 
after marriage, is, in the vast majority of cases, the result of an in- 
flammation of the endometrium or of the uterine wall. 



ENDOMETRITIS 493 

Bleeding and pain are symptoms which belong also to other con- 
ditions than inflammation, but discharge or fluor is a proof of in- 
fection. The discharge may be seropurulent or purulent, or, in 
chronic cases, it may form a thin watery fluid of purulent ap- 
pearance. Often the secretion is very slight, The largest amount 
is observed in gonorrhea in pregnancy. Fluor has a tendency to 
increase before and after menstruation, but sometimes may stop 
entirely for varying periods. Mucoid fluor always means discharge 
from the cervix. Pure pus, if the vagina be excluded, comes from 
the uterus. It is necessary to distinguish, by the aid of the Schultze 
tampon, between secretion from the vagina and secretion coming 
from the cervix or uterus. Care must be taken in this event, for 
erosions stain the cotton a light yellow. In distinguishing be- 
tween cervical and uterine discharge on the Schultze tampon, we 
may say that if mucus and pus are well mixed, the combined se- 
cretion probably comes from the cervix. If pus and mucus are 
not mixed, and if there is much more pus than mucus, the corpus 
of the uterus is also involved. The absence upon the tampon of 
cervico-uterine secretion of a pathologic nature is no proof that 
fluor does not exist, and additional examination should always 
be made before and after menstruation. Fluor or discharge is a 
frequent symptom of involvement of the endometrium, and, of 
course, when met with, indicates an inflammatory invasion of the 
uterine lining. It is most frequently associated with cases of 
gonorrheal origin, and is then especially marked during pregnancy. 
It must always be suspected that all stubborn uterine catarrhs 
which persist after treatment are of gonorrheal origin, even if we 
cannot find the gonococci in the discharge and even if the uterine 
adnexa and the periuterine tissues are normal. It must be con- 
sidered an axiom, that simply the absence of gonococci on micro- 
scopic examination of a purulent or catarrhal uterine discharge 
never excludes gonorrhea. 

Pre-menstrual Symptoms. — There may be a sensation of pres- 
sure or a f eeling of swelling in the genito-urinary tract. The patients 
seem conscious of the presence of a sensitive uterus. There is a 
desire for frequent urination; there is a sensation of pressure in 
the rectum, there is pain in the back and in the legs. These symp- 
toms are related to menstruation and its associated congestion. 



494 MEDICAL GYNECOLOGY 

There are other symptoms of a general nature. The patients are 
nervous or tired or excitable. They have a restlessness that is 
sometimes maniacal. There is palpitation of the heart; there is 
change of temperament, which is marked. They are mentally 
upset and changeable, sometimes melancholy. These symptoms 
are exaggerations of the complaints which even healthy women feel 
at this time. While such symptoms are not infrequently found 
without metritis and without inflammatory tubal and ovarian dis- 
eases, they occur most frequently in women suffering from catarrhal 
endometritis, in whom, be it said, metritic, tubal, and ovarian 
changes often escape detection on bimanual examination. 

Objective Signs of Endometritis. — Examination of the 
uterine cavity by the sound often shows, with involvement of the 
endometrium, an enlarged cavity. (This may also be observed 
with uterine polyps, after abortion, with subinvolution, and with 
uterine atony.) The lining of the uterus may seem thick and soft; 
it may bleed on the use of the sound. Excrescences, when present, 
are most often felt in the fundus and tubal corners. The excres- 
cences are most marked with the fungoid form of endometritis. 
The lining of the uterus may seem rough to the examining sound 
(also with carcinoma, retention of decidua, etc.). On the other 
hand, the endometrium when involved is often smooth, especially 
with the inflammatory atrophic forms, and even in some cases 
of the diffuse hyperplastic form. Fungoid endometrium bleeds 
easily on the use of the sound. On the other hand, the introduc- 
tion of this instrument is not infrequently accompanied by pain. 
As a rule, this symptom of pain on the use of the sound means an 
inflammatory involvement. (There are cases, however, in which 
the reaction of pain to the use of the sound is due to a hyper- 
esthesic state.) The pain felt on the use of the sound may be noted 
in or near the umbilicus or the back, and this fact must be taken 
into consideration. If due to endometritis and not to perimetritic 
conditions, the pain is noted when the sound enters the uterus, and 
not when, by moving it, the uterus is also moved. 

VARIETIES 
Endometritis Fungosa. — Fungoid or hyperplastic glandular 
endometritis implies an overgrown mucous membrane. The 



ENDOMETRITIS 495 

change is of a glandular character and diffuse. Endometritis 
fungosa means endometrium so overgrown and thick that it pro- 
jects above the surface of the uterus. It feels thick and mossy to 
the sound and large amounts are obtained by the curet. If no 
interstitial changes occur, it is simply a hyperplasia, especially of 
the glands. It is in contrast to the purely interstitial forms, where 
atrophy is the rule. In the purely hyperplastic non- inflammatory 
form the only symptom is menorrhagia. Dysmenorrhea and dis- 
charge are absent. The cavity of the uterus is enlarged and the 
use of the sound is not accompanied by pain. The use of the 
Schultze tampon shows no discharge. There is no parametritis, 
perimetritis, or tubal disease, and there are no other evidences of 
inflammation. There is usually a history of previous abortion or 
evidences of subinvolution are noted. This condition may be 
present in virgins as a result of over- stimulation by the ovarian 
secretion, or as a result of failure of trophic control over the endo- 
metrium by ovaries involved by the diseases of children. Dis- 
placements are a factor only if congestion is present dependent on 
poor circulation, subinvolution, etc., as is also the case with nor- 
mally situated uteri. Since the uterine lining is a lymphoid tissue, 
is quite possible that in the so-called lymphatic constitution the 
uterine lining may undergo hyperplastic changes as a part of a 
general condition of lymphatic hypertrophy. This may explain 
the hyperplasia of the mucosa and menorrhagia present in young 
girls without apparent cause. In addition to the purely glandular 
form, we have a glandular and an interstitial, which means either 
inflammation added on to an endometrium involved in glandular 
hyperplasia or else the glandular hyperplasia is due to the con- 
gestion which is associated with an active inflammation of so acute 
or deep a nature as to involve the uterine wall or the adnexa or the 
periuterine vessels and so cause a permanent congestion in the 
uterine lining, for congestion is the important element in the pro- 
duction of hyperplasia oj the endometrium. The endometrium often 
feels rough to the sound. Excrescences may be felt. 

Sapremic Endometritis. — There may be a saprophytic in- 
volvement of the uterine lining by bacilli, by bacteria, by cocci, 
and the proteus vulgaris, which grow on dead material represented 
by placenta, decidua, degenerating tumors, carcinoma, etc. In 



496 MEDICAL GYNECOLOGY 

puerperal endometritis Kronig examined one hundred and seventy- 
nine cases; fifty were due to saprogenic bacteria, generally cocci, 
the so-called putrefactive bacteria. They do not grow on healthy 
tissue or in the blood. Kronig never found them with streptococci 
or staphylococci. In the putrid form of endometritis the necrotic 
tissue is separated from healthy tissue by granulation. The 
necrotic area is thrown off, the round cells are absorbed and 
normal mucosa returns. The discharge is foul-smelling. Temper- 
ature and rapid pulse are present. The condition is an intoxica- 
tion by the ptomaine products produced by the saprophytic bac- 
teria. These do not grow on living tissue. 

Septic Endometritis. — Acute septic endometritis is character- 
ized by fever, discharge, and other evidences of pelvic inflamma- 
tion, and occurs after abortion, labor, operations, curettings, and 
intrauterine manipulations. The earlier the onset of fever and 
pain, the more severe it is. The deeper into the uterine wall the 
affection extends, the more severe it is. If it is limited to the 
mucous membrane, even if streptococci are found in the lochia, 
there is euphoria. The pain comes on with involvement of the 
peritoneum or parametrium. There is a purulent discharge which 
has no odor unless saprophytes are present. The course is simple 
if limited by granulations under the decidua. The course is severe 
if the infection extends deep into the uterus, into the lymph-spaces, 
into the lymph-spaces of the parametrium, or if there is thrombo- 
phlebitis or if the general circulation is involved. Among the 
changes occurring in the uterine wall are either metritis dissecans, 
intramural abscess, or chronic metritis. Infection by the gono- 
coccus must be excluded by repeated examination. 

Gonorrheal Endometritis. — The infiltration occurring in this 
inflammation is often observed only in isolated areas and mostly 
around the glands. There is often an added exudative inflam- 
mation. The surface epithelium is gone in many places and the 
glands show inflammatory growth. The mucosa is thickened, 
the surface is rough, and there are small overgrowths. There is 
a marked interstitial inflammation with very great pus and round- 
celled infiltration. There is a purulent secretion. Its irritating 
action causes burning, ulceration, secondary changes, and sore- 
ness in the vulva. If it invades the uterine wall, there is acute 



ENDOMETRITIS 497 

metritis. The uterus is enlarged and sensitive. The portio is 
swollen. There is a sensation of -weight and pain in the pelvis. 
There is a vaginitis granulosa and a papillitis. 

In younger women or in women with tender epithelium and in 
pregnant women the term gonorrheal endometritis is used, in con- 
tradistinction to the term catarrhal endometritis, when the ex- 
amination of the uterine discharge gives positive evidences of the 
presence of gonococci. Here the process is one which is fresh 
or still active, and is often, unfortunately, kept active by intra- 
uterine treatment. Very frequently there is a deeper involvement 
than in the ordinary superficial infection. There are many cases 
where the inflammation is superficial, has become quiescent, and 
restoration to the normal is beginning. No gonococci can be 
found, but, in addition to pus cells and epithelial cells, squamous 
cells may be present. To this form, of necessity, the term catarrhal 
endometritis is given. In endometritis gonorrhceica the gonococci 
have been found or are still found. The affection of the endo- 
metrium, then, in many cases is of secondary importance, for there 
are complicating conditions, such as salpingitis, pyosalpinx, para- 
metritis, peritoneal and ovarian involvements. In such cases gono- 
cocci may be found for weeks and months in the uterine discharge. 
The symptoms of the acute stage are those of a mild or diffuse pel- 
vic peritonitis and the periuterine symptoms dominate the situation. 

Catarrhal Endometritis. — This is characterized by hyperemia 
and infiltration. There is a secretion of a seropurulent character. 
There are pre-menstrual symptoms. Menorrhagia is rare. Dys- 
menorrhea, in the superficial involvement of the endometrium, is 
seldom a symptom, but it is more marked with the deeper involve- 
ments of the mucosa or with involvements of the uterine wall. 
There are no excrescences, no pain to the sound, with superficial 
involvement. The Schultze tampons should be used and are of 
importance in the diagnosis. Periuterine alterations should al- 
ways be looked for, and are frequently found on repeated exami- 
ation or on examination under narcosis. It cannot be denied that 
a catarrhal endometritis may be due to non-virulent streptococci, 
staphylococci, bacterium coli, or to saprophytes. There may 
result an inflammation of a subacute form, subsequent to an acute 
septic involvement. In other cases it is possible that these bac- 
32 



498 MEDICAL GYNECOLOGY 

teria from the beginning have been of a mild saprophytic type. 
It is the natural tendency to incline to this view and to exclude the 
gonococcus as an etiologic factor when repeated examinations show 
no gonococci, and especially if the periuterine structures seem 
normal. I believe, however, that most persistent uterine catarrhs, 
except such as follow acute septic infection, and such as come on at 
or after menopause or on the retention of fetal tissues, especially 
if they resist conservative treatment, even if no gonococci are pres- 
ent, are originally gonorrheal in their etiology. I therefore believe 
that the vast majority of cases of catarrhal endometritis this side of 
the climacteric period are to be referred to mild superficial gonor- 
rheal infection, by supposed or objectively cured diseases of the 
prostate. 

Endometritis Dysmenorrhoeica. — If accompanied by menor- 
rhagia and fluor, attention is readily drawn to an involvement of 
the endometrium. This condition may be present without men- 
orrhagia, but is often accompanied by fluor. Sometimes there is 
neither hemorrhage nor fluor, but only nervous symptoms. Endo- 
metritis dysmenorrhoeica is that form in which there is an inter- 
stitial exudation, but the objective evidences of inflammation are 
not so marked as in the other inflammatory forms. Menstruation 
is painful and the use of the sound causes pain. The pain felt 
in this condition is to be attributed to the exudative process. It is 
probable that many of these cases are simply the inflammatory 
form with a minimal amount of discharge. Endometritis dys- 
menorrhoeica, as a rule, implies inflammation. 

Senile Endometritis. — Beyond the climacterium occurs an 
endometritis accompanied by bleeding and disagreeable fluor, 
symptoms which resemble carcinoma. A non-resistant endometrium 
permits the growth of saprophytic bacteria, and the condition is 
comparable to the vaginal state in senile vaginitis of older women. 

Endometritis deciduae is an inflammation of the endometrium 
occurring during pregnancy, and producing symptoms which are 
most marked in the first half of pregnancy. The symptoms are 
fluor, bleeding, and pain. The bleeding begins early and may 
last for weeks or months. The blood is mixed with mucus. The 
discharge is purulent, especially with gonorrhea. It is sometimes 
watery, furnishing the form known as hydrorrhcea uteri gravidi. 



ENDOMETRITIS 499 

The Schultze tampon should be used. Pain is frequent; it takes 
on the character of uterine contractions and may last for months. 
This primary condition often gives symptoms before pregnancy, and 
abortions are frequent. The expelled particles, when examined^ 
show inflammatory changes. 

Membranous Endometritis. — Membranes thrown out by the 
uterus are (i) unorganized, i. e., fibrin membranes thrown out 
w T ith symptoms of dysmenorrhea; (2) organized membranes 
thrown out with dysmenorrhea and representing larger or smaller 
parts of altered uterine mucosa. They are smooth on their 
inner surface and show the openings of the glands. On the ex- 
ternal surface where they are torn off they are irregular. They 
give the general picture of interstitial exudative endometritis with 
small round-celled infiltration. Sometimes we get a picture of 
combined interstitial and glandular increase. In the more severe 
forms where the uterine lining is thrown off in the form of a mem- 
brane, inflammatory evidences by the microscope are also present, 
and it is probably well to consider all these changes as the result of 
bacterial involvement either during childhood or at a subsequent 
stage. The exudative swelling is the probable cause of expulsive 
efforts on the part of the uterus. There are generally small round 
cells present. There are sometimes large cells, which look like 
decidual cells. It is then hard to diagnose from the decidua of 
pregnancy, but the change in this membrane is not so regular as 
in decidua and the framework between the cells is not so homo- 
geneous, but is finely fibrous and loose and the glands are generally 
compressed. Dysmenorrhea membranacea is rarely diagnosed now, 
for formerly this name was given to what we now know to con- 
stitute a throwing off of decidua after abortion or with ectopic 
gestation. The real cases are such as at every menstrual period 
throw off with marked pain a membrane of the character of uterine 
mucosa altered by inflammation. It is difficult to cure and curet- 
tage must be done. 

SEQUEUE 

The results of involvement of the endometrium take various 
forms. If there is abnormal secretion it may have a bearing on 
the location of the ovum, if it be embedded at all. Altered charac- 



500 MEDICAL GYNECOLOGY 

ter of the endometrium is probably responsible for that embedding 
of the ovum in the lower end of the uterus which results in placenta 
praevia. If the endometrium, as the result of chronic inflammation, 
is smooth and atrophic, it cannot readily accommodate the embed- 
ding of the ovum, or else the change to decidua is not a normal one. 
Therefore involvement of the endometrium may prevent conception, 
may prevent embedding, may be the cause of sterility or the cause 
of habitual abortion. Sterility is frequently the result of the in- 
flammatory atrophic form. The most frequent involvements of 
the endometrium are those associated with discharge and dys- 
menorrhea. With the chronic hyperplastic form, in which bleed- 
ing is so frequently a symptom, sterility is not the usual result. 
Here, because of the congestive hyperemia and ready bleeding, we 
are frequently concerned with single and repeated abortions at a 
very early stage. 

TREATMENT 

The treatment of acute septic endometritis demands rest in 
bed, fluid diet, attention to the bowels, and the usual sustaining 
and antipyretic treatment associated with pelvic inflammation. 
An ice-bag or ice-coil should be applied to the abdomen and short, 
very hot vaginal douches of J per cent, lysol should be given 
several times a day. Locally, treatment demands the very careful 
use of intrauterine douches given with a double-running catheter. 
These douches may consist of i per cent, lysol or of dilute acetic acid, 
2 ounces to each quart of water. Internally the use of fluidextract 
of ergot 30 minims, or, better still, of ergotol 15 minims, or of ergotin 
2 grains, from four to six times daily, .is advisable to contract the 
uterine wall and to prevent or limit by this means the rapid ex- 
tension of the invading micro-organisms into the lymphatics of 
the uterine wall. When a septic endometritis spreads out and in- 
volves the parametrium or the tubes, or the peritoneum or the 
general circulation, the condition is no longer an endometritis and 
surgical considerations are often essential. 

The treatment of sapremic endometritis demands removal by the 
dull curet or by the finger of adherent necrotic fetal or maternal tissues. 

The treatment of acute gonorrheal endometritis demands rest 
in bed, fluid diet, and daily short hot douches of bichlorid of mer- 



ENDOMETRITIS 501 

cury i : 10,000 to 1 : 5000, alternating with hot douches of h per cent, 
acetate of aluminum several times a day. The ice-bag should be 
applied to the abdomen or the ice-coil should be used. The as- 
sociated vulvitis or urethritis or other complications should be 
treated according to the methods explained under those headings 
1 see Gonorrhea ). A very long period of rest in bed is essential and 
the patient should not be permitted to get up until she has been 
free of temperature for at least two weeks. With even* acute 
gonorrheal endometritis there is associated more or less metritis 
and, in the vast majority of cases, extension to the connective tissue, 
tubes, or peritoneum. Long continuation of temperature with 
great pain and distention, etc., speak for peritoneal involvement. 
With high temperature and marked pain, repeated careful local 
examination is essential, for connective-tissue, tubal, and peri- 
toneal complications may demand surgical intervention. 

The treatment of chronic gonorrheal endometritis is given in the 
section on Gonorrhea (p. 400). 

In " endometritis' ' we are dealing with a uterine lining;, altered 
in character and structure, sometimes associated with atrophy of 
the mucosa, ofttimes with hyperplasia of the mucosa, and evidenc- 
ing either inflammatory changes or no inflammatory* changes. 
We are also concerned in many cases with a uterine cavity larger 
and more roomy than normal. Hand in hand with these altera- 
tions of the mucosa are alterations in the character of the uterine 
wall. The uterine wall may be altered as a result of inflamma- 
tion. Without inflammation the uterine wall may be thickened 
and congested, or it may be thickened as a result of hypertrophy 
of the muscle fibers or increased growth of the fibrous connective 
tissue or change of the elastic fibers to fibrous bundles. The 
capillaries and blood-vessels of the mucosa may be dilated and 
greatly increased in number, the vessels of the uterine wall may be 
congested or dilated, and there frequentlv exists about the uterus 
dilated arteries and veins, or else changes of an inflammatory 
nature are present. 

Hence the symptoms are excessive menorrhagia or a discharge 
due to congestion or to inflammation, or pain due to the uterine 
contractions of a sensitive uterus expelling secretions of the mucosa, 
or there may be dysmenorrhea due to the congestion occurring in 
an inflamed uterus or to obstruction to the outflow of blood. 



502 MEDICAL GYNECOLOGY 

The treatment of endometritis depends upon the cause, upon 
the symptoms, and on the result which it is desired to obtain. The 
medical treatment of hyperplastic endometritis is directed to the 
treatment of the menorrhagia or the metrorrhagia. It implies the 
use of ergot, ergotol, or ergotin, of hydrastis or hydrastinin hydro- 
chlorate, of stypticin, styptol, of suprarenal extract, adrenalin, 
or ferropyrin and the hot-water bag applied to the lower vertebrae. 
Irregular bleedings which occur if decidua is left behind after 
abortion, and bleedings which occur on the presence of overgrown or 
polypoid endometrium or which continue after the medical treat- 
ment of hyperplastic endometritis, demand the use of the curet. 

In dealing with a hyperplastic endometrium whose only symptom 
is bleeding, we are concerned with the use of internal remedies, the 
best of which is stypticin. Stypticin should be given in doses of 2 
to 4 grains several times a day, beginning two or three days before 
menstruation, and continued during menstruation. A very good 
combination consists of ergotin 2 J grains, stypticin 2 J grains, and 
suprarenal extract 2J grains in capsules, given four to six times a 
day. Between menstruation, especially if the uterus is enlarged or 
the cavity is enlarged, ergotol 1 5 minims, and .fluidextract of hydrastis 
15 minims, should be given four times a day. A regular course of 
sitz-baths 70 to 85 , five to fifteen minutes is valuable. In cases 
in which the loss of blood is very marked, or in which the menor- 
rhagia goes over into metrorrhagia or irregular bleedings, curetting, 
with or without atmocausis, must be done. (See Uterine Bleeding.) 

With endometrial hyperplasia there often comes a time when the 
curet is necessary. The use of the curet may be followed later on 
by the application of 10 to 20 per cent, chlorid of zinc, or 10 to 20 
per cent, pure tincture of iodin or 50 per cent, carbolic alcohol. 
Care should be used in introducing these fluids into the uterus, for 
they readily pass into the tubes. It is better to use cotton rolled on 
a Playfair sound or to introduce into the uterus a syringe with its 
tip covered with cotton, and then to slowly inject the fluid so as to 
moisten the cotton covering. Even curetting fails to cure the bleed- 
ing in a fair proportion of cases. The use of intrauterine medicated 
suppositories is dangerous if cauterizing drugs are used, because 
of the possibility of causing a stenosis. 

An inflammatory endometritis not associated with severe bleed- 
ing should not be curetted. It is wisest to treat these cases without 



ENDOMETRITIS 503 

intrauterine manipulation. Some treat them, however, by dilata- 
tion of the cervix with Hegar dilators or with sounds, and daily in- 
trauterine irrigations with i per cent, lysol, i to 2 per cent, carbolic, 
1 : 3000 sublimate, or J ounce of Lugol's solution to the quart. 
These irrigations are then done two or three times a week. Later 
on, with a wide cervical canal the uterus may be irrigated and 
tincture of iodin or 5 to 10 per cent, chlorid of zinc may be applied. 
In other instances medicated sticks containing 10 per cent, iodoform 
or 2 to 5 per cent, protargol may be introduced into the uterus two or 
three times a week. My usual method is the use of glycerin in the 
vagina, well applied with the aid of gauze. A very good aid con- 
sists in the use of daily vaginal douches of several quarts of cold 
water, beginning first with tepid and gradually cooling it down in 
the course of weeks. When continued for weeks, they have an ex- 
cellent effect on the uterus. In other cases the use of steam may be 
followed with fair results. In the treatment of acute and subacute 
gonorrhea, although some dilate the cervix and make use of the 
above method, it is wiser to use no intrauterine treatment. Every 
stubborn uterine catarrh which resists conservative treatment is 
possibly gonorrheal. We then depend on the use of the cold douche 
cure, the administration of sitz-baths to produce temporary hy- 
peremia, the use of tonics, and such an arrangement of the patient's 
routine as will prevent congestion. (See also pages 401, 402, 403, 
404.) 

For the treatment of pre-menstrual symptoms bromids are the 
best, given in the dose of 10 grains of strontium bromid in water 
four to six times a day. In extremely excitable cases hyoscin 
hydrobromate, -jitq °f a g ram > mav be given three times a day. 
Its effects should be watched, as some patients are extremely sus- 
ceptible to the drug. For the treatment of pain see Dysmenorrhea. 

For senile endometritis intrauterine irrigations with lysol solu- 
tion or 1 to 2 per cent, carbolic acid, with treatment of the associated 
vaginitis with pyroligneous acid, should be carried out. 

For endometritis membranacea the internal administration of 
ovarin and iodid of potash should be continued for a long time. 
For the pain experienced at menstruation the drugs mentioned 
under dysmenorrhea, and consisting mainly of the coal-tar products, 
should be used. A thorough curetting followed by the use of steam 
is the best form of treatment for endometritis membranacea. 



INFLAMMATORY METRITIS 

i. Bacteria may thrive in the uterine cavity in puerperal affec- 
tions, after operations or artificial abortions. 

2 . The introduction of pyogenic bacteria into the uterus in non- 
puerperal conditions may produce acute infection, if at the same 
time we have an injury to the endometrium. 

3. Gonococci can grow in the healthy tissue of the endometrium, 
though their activity is increased by curettage, labor, and especially 
by abortion. 

Acute Endometritis after Labor, etc. — The course of an acute 
endometritis occurring after labor, after operations, after the use 
of the curet, or subsequent to artificial abortions may be limited 
and held within bounds by granulations in the endometrium or the 
decidua. There may, however, result deeper involvement, pro- 
ducing intramural abscesses or numerous miliary foci or chronic 
diffuse metritis. 

Septic pyogenic endometritis is due to streptococci, staphylococci, 
and the bacterium coli. Involvement may be superficial. It is 
characterized by round-celled infiltration. A granulation area 
is formed under the necrotic tissue. If the granulation area is 
strong enough, there is no deep invasion. Otherwise the septic 
involvement extends into the muscularis. When recovery takes 
place there is formed intramuscular connective tissue and indura- 
tion results. 

Gonorrheal Involvement of . the Endometrium. — Gonor- 
rheal involvement of the endometrium is characterized in the acute 
stage by an interstitial involvement with small-celled infiltration. 
The glands are filled with secretion and epithelia and the inter- 
stitial tissue consists of closely grouped small cells and round cells 
and smaller round pus cells. Madlener found gonococci in the 
infiltration foci of the muscularis, which proves that the muscular 
changes are not due to the bacteria or cocci of a mixed infection. 
If gonococci are in the uterus, according to Wertheim, they may 

5°4 



INFLAMMATORY METRITIS 505 

invade the uterine wall and cause an acute metritis with enlarged 
uterus, sensitive uterus, red swollen portio, pain and weight in the 
pelvis, erosions of the cervix, and granular vaginitis. Chronic 
metritis may be the result of acute cases as above, in which event 
there is a history of such a condition. Gonorrheal endometritis 
post partum often causes few symptoms, and the rise of tempera- 
ture associated with it is slight or minimal. Kronig examined 
one hundred and seventy-nine cases of puerperal endometritis and 
found gonococci in the lochia of fifty. Wertheim took five cases 
of fresh gonorrhea in whom the adnexa were normal and in whom 
there were no subjective symptoms of an affection of the endomet- 
rium. He curetted particles from the corpus mucosa, examined 
the sections, and found gonococci in them all. Chronic metritis 
may result from an involvement which was never acute. 

Wertheim finds that the uterus in chronic gonorrhea is enlarged, 
the wall is thickened and hard, and the mucosa is thickened to 5 
mm. Microscopically there is a great infiltration by pus and 
round cells, either diffuse or in spots around the glands. There is 
edema of the interstitial tissue. 

Inflammation in the Connective Tissue and in the Mus- 
cularis. — Inflammation occurs in the connective tissue between 
the muscle bundles. Such inflammation comes from the endo- 
metrium. In acute inflammation there is an accumulation of 
leukocytes. The muscle bundles are forced apart by serous exu- 
dation and a doughy swelling of the uterus results. Chronic inflam- 
mation leads to the development of connective tissue between the 
muscle fibers, which then gradually become atrophied. The 
uterine wall is finally much thickened by connective tissue and 
forms a hard mass. An important consequence is lack of contractile 
power on the part of muscle fibers and the presence of an excessive 
amount of connective tissue. Such conditions complicate very 
many cases of endometritis, gonorrheal and catarrhal, and are more 
responsible for the symptoms and annoyances than are the changes 
in the endometrium. 

In every case of inflammatory metritis we have an associated 
inflammatory endometritis. In other words, with many cases of 
endometritis the uterus is so involved as to constitute a metro- 
endometritis. The very fact that an acute involvement extends 



506 MEDICAL GYNECOLOGY 

into the muscularis makes the acute disease more grave and more 
lasting and renders a chronic condition less amenable to restora- 
tion to the normal. In addition to the fluor and pain of a chronic 
inflammatory endometritis, there is such an alteration of the mus- 
cular wall as renders menstruation more profuse, of longer dura- 
tion, and often of an irregular character. 

There is a feeling of weight in the pelvis, the portio is thickened 
and the uterus is enlarged. There are erosions, hypersecretion, 
uterine fluor, irregular bleedings, either menorrhagia or metror- 
rhagia, especially in the cases which were once acute. 



TREATMENT OF METRITIS 

The treatment of acute metritis is like that of acute endometritis, 
but more prolonged. Rest in bed, the use of the ice-bag or the ice- 
coil, fluid diet, attention to the bowels, the sustaining and antipy- 
retic treatment usually carried out in fevers. Short hot vaginal 
douches should be made use of several times a day and should con- 
sist of i : 10,000 or 1 : 5000 bichlorid or \ to 1 per cent, lysol. 
With most careful precautions there should be given daily one or 
two intrauterine irrigations with a double-running catheter in post- 
partum or abortion cases. These irrigations may consist of very 
mild solutions of bichlorid of mercury or very weak carbolic acid 
solution, but best of all is 1 per cent, lysol, or dilute acetic acid 2 
ounces to each quart of water. Internally ergotol 15 minims or 
ergotin 2 grains should be given four to six times a day. This treat- 
ment applies to septic metritis and not to gonorrheal metritis, unless 
the latter is post partum. 

The treatment of gonorrheal metritis is rest in bed, the use of 
vaginal douches, etc., as prescribed under gonorrheal endometritis. 
Because of its importance, I repeat the essential points. 

The treatment of acute gonorrheal metro- endometritis demands 
rest in bed, fluid diet, and short hot douches of bichlorid of mer- 
cury 1 : 10,000 to 1 : 5000, alternating with short hot douches of \ 
per cent, acetate of aluminum several times a day. The ice-bag 
should be applied to the abdomen or the ice-coil should be used. 
The associated vulvitis or urethritis or other complications should 
be treated according to the methods explained under those head- 



INFLAMMATORY METRITIS 507 

ings (see Gonorrhea). A very long period of rest in bed is essen- 
tial and the patient should not be permitted to get up until she has 
been free of temperature for at least four weeks. With every acute 
gonorrheal endometritis there is associated more or less metritis, 
and in the vast majority of cases there is extension to the connective 
tissue, tubes, or peritoneum. Long continuation of temperature, 
with great pain and distention, etc., speak for peritoneal involve- 
ment. With high temperature and marked pain, repeated careful 
local examination is essential, for the connective tissue, tubal and 
peritoneal complications demand surgical intervention. 

In the treatment of chronic metritis the patient should lead a life 
free of effort and lifting and all physical strain should be avoided. 
Coitus and other conditions which increase the congestion should 
be eliminated. Daily douches should be taken of several quarts 
of hot water, making use of bichlorid of mercury i : 10,000 to 
1 : 5000 or lysol J per cent, or some of the astringent powders, 
such as alum, or tannic acid or sulphate of zinc 1 dram to each 
quart of water. The associated erosions should be treated by 
direct application of carbolic acid, followed by the application of 
tincture of iodin, as described in the section on Cervical Catarrh. 
For the uterine congestion and inflammation glycerin treatment is 
the best. This is carried out by the use of glycerin (boroglycerin or 
5 to 10 per cent, ichthyol- glycerin being used). Glycerin acts well 
when applied in large amounts. It is better applied as follows: 
With the bivalve speculum in place, and after cleansing of the for- 
nices and the treatment of the erosions, 1 or 2 ounces of the glycerin 
is poured into the vagina, and then a long strip of sterile gauze, 6 
to 8 inches wide and a yard long, is thoroughly packed first into 
the posterior fornix and then into the other fornices and then into 
the vagina, after which the speculum is removed. This is allowed 
to remain in place for twenty-four hours, during which time the 
patient wears a vulvar pad, for the amount of fluid extracted by the 
glycerin is very large. The strip of gauze is removed at the end of 
twenty-four hours and is followed by a douche of the above- 
mentioned drugs or by a vaginal douche containing a dram 
of acetate of aluminum to each quart of water. This application of 
glycerin should be carried out three times a week, and the hot 
vaginal douches should be taken twice every day, except during 
the twenty-four hours when the gauze is in place. 



508 MEDICAL GYNECOLOGY 

Rest in bed during menstruation is very essential, and short hot 
douches should be ordered during menstruation. 

For the bleeding, stypticin, 2 grains in capsules four to six times 
a day, should be taken, best begun two or three days before the 
bleeding is expected, if the time can be gaged. With the stypticin 
2 grains of ergotin and 2 grains of suprarenal extract may be com- 
bined. Between menstrual periods ergotol, 15 minims four times a 
day, should be given, or ergotin 2 grains plus hydrastinin hydro- 
chlorate J grain should be given in capsules four times a day. 
Curetting should not be attempted in metritis unless the bleedings 
are so profuse as to endanger the patient's health. Curetting 
should then be followed by the use of steam, in the manner ex- 
plained in the section on Atmocausis. 

In the treatment of chronic metritis (due to bacteria), associated 
with congestion, infiltration, edema, but before the formation of new 
connective tissue and sclerosis, heat is used only if there is no pus 
about the uterus. Hot Priessnitz bandages are used, hot coil, hot- 
water bags, warm sitz-baths, hot vaginal douches. In the late 
stages, when sclerotic changes are prominent and menorrhagia and 
metrorrhagia are marked, sitz-baths and douches which produce 
pelvic anemia are substituted and scarification with suction may 
be used. If there is no metrorrhagia or menorrhagia Nauheim 
baths with an after- cure are advisable. 

Inasmuch as the treatment of chronic metritis implies also the 
treatment of chronic catarrhal or gonorrheal endometritis, it is 
well to state that some treat these conditions by intrauterine ap- 
plications or irrigations. Hence the reader is referred, in this 
connection, to the treatment of chronic gonorrhea as made use of 
by Bumm, Boldt and others, in the section on Chronic Gonorrhea 
(pages 401, 402, 403, 404). 

Cases of chronic metritis are eventually, but not temporarily, re- 
lieved of the sense of weight and discomfort in the pelvis and of the 
pain experienced between menstruation by the use of sitz-baths con- 
taining 2 to 3 pounds of sea salt and 3 to 4 ounces of calcium chlorid 
taken for a period of fifteen to twenty minutes before retiring at a 
temperature of 90 . In place of the bath, the abdomen may be 
covered all night with a wet cloth over which oiled silk and chamois 
is applied and kept in place by an abdominal binder of muslin, or 
a long, wide towel, or Neptune's girdle may be used. 



INFLAMMATORY METRITIS 509 

The full Nauheim baths are often of marked benefit in the 
cases without bleedings, having the same local effect as sitz-baths, 
coupled with which is the general systemic benefit due to their 
action. 

The menstrual pain associated with menstruation is treated by 
the coal-tar products, etc., as described in the section on Dys- 
menorrhea (p. 151). 



PELVIC CELLULITIS AND PARAMETRITIS 

Point of Origin of the Infection. — The cervical portion of the 
uterus in particular is embedded in and surrounded by a large 
amount of cellular connective tissue. This connective tissue 
spreads out in the form of a six-pointed star. Each arm is 
covered by peritoneum and contains muscle fibers, blood-vessels, 
and lymphatics. Thus are formed the two broad ligaments, the 
two antero-lateral or uterovesical ligaments, and the two postero- 
lateral folds of Douglas or uterosacral ligaments. The base of the 
broad ligaments, called the ligamentum cardinale, is particularly 
rich in lymphatics. The cellular tissue posterior to the cervix, 
lying above the posterior fornix of the vagina and underneath the 
peritoneum of the cul-de-sac of Douglas, is also rich in lymphatics. 
The pelvis, underneath the peritoneum, is lined with connective 
tissue, the cellular connective tissue of the pelvis. It is in direct 
connection with the connective tissue of the six ligaments united 
with the cervix. To the connective tissue of the six-pointed star, 
in particular, is given the name parametrium, and a further desig- 
nation is added by the terms lateralis, anterior and posterior. 
The cellular connective tissue of the upper part of the broad liga- 
ment and along the tube and near the ovary, together with the great 
plexus of veins, is of the greatest importance because of its frequent 
and frequently unrecognized involvement. 

Acute Cellulitis. — Pelvic cellulitis or parametritis is an acute, 
subacute, or chronic inflammation affecting the connective tissue 
under the peritoneum of the pelvis, but more especially involving 
the connective tissue situated in the broad ligaments (ligamenta 
lata), the vesico- uterine ligaments, or the uterosacral ligaments, 
the latter also being known as the folds of Douglas. An acute 
parametritis is a phlegmon beginning from an infected wound in 
the cervix. In acute parametritis streptococci are most frequently 
found, but staphylococci, bacterium coli, and the proteus vulgaris 
are also responsible, and so is the gonococcus, the latter, as a rule, 

510 



PELVIC CELLULITIS AND PARAMETRITIS 51I 

in association with other bacteria. Involvement of the connective 
tissue of the pelvis readily occurs, because of the numerous lymph- 
atics present in the parametrium surrounding and connected 
with the uterus and cervix. In the acute form the broad ligaments 
are easily involved because of the lateral tears occurring in labor, 
and symptoms are manifested between the second and the eighth 
day. Injuries of the same character may occur at operation on the 
cervix, especially when dilatation of the cervix opens up the same 
avenues of approach. The uterosacral ligaments and the posterior 
parametrium are also involved post partum and after abortion, but 
usually manifest symptoms at a somewhat later period. The 
most severe forms of parametritis are the acute phlegmonous in- 
flammations combined with inflammation of the peritoneum. A 
more frequent form is acute phlegmon without involvement of the 
peritoneum. It is characterized by sero-gelatinous, yellow, in- 
filtrating exudate and by small round- celled infiltration. 

The Puerperal Form. — As stated, the early puerperal form 
often involves the ligamentum latum and is associated with tender- 
ness and some pain in one side, with temperature. There is soft 
elastic exduation with edema in its periphery, situated lateral to 
the uterus. There results after a few days a large tumor at the 
side of the uterus, extending high up into the broad ligament and 
over toward the pelvic wall. Since it is limited by the peritoneum 
of the broad ligament, its upper surface is rounded. Another fre- 
quent location is posterior to the cervix, that is, retrouterine and 
retrocervical, in which event the exudate also surrounds the rectum 
and extends into the rectovaginal septum. In this form the upper 
surface of the exudation may be round, when covered by the peri- 
toneum of the sac of Douglas. If connected with the vagina, there 
is evidenced a flat infiltration underneath the mucosa of the pos- 
terior wall, ending on the posterior wall with a sharp edge. 

Location of the Exudate. — A parametritic exudate may ex- 
tend up on the anterior abdominal wall above Poupart's ligament, 
and may pass around the bladder and up on the anterior abdominal 
wall. The inguinal glands may be involved. The exudate may 
surround the uterus and the rectum in addition to lining the pelvis. 
The basic lesions are lymphangitis and venous thrombosis. 

Acute parametritis in the broad ligament shows a swelling lateral 



512 MEDICAL GYNECOLOGY 

to the uterus, extending from the uterus up to the pelvic wall. If 
it does not extend entirely up to the pelvic wall, it is slightly mov- 
able ; otherwise, not so much so. It may be irregular at its lower 
border, and when pus formation occurs it may project into the 
lateral fornix. The upper border is found and readily felt by the 
external hand, extending in some cases up to the level of the um- 
bilicus. When slight peritonitis is combined, the upper border 
may be indefinite through adhesion of intestines. The presence 
of pus is marked by higher temperature, chilly feelings or chills, 
and by evening rises and morning remissions. If no suppuration 
takes place, there is temperature, but otherwise relatively little 
discomfort. 

Differential Diagnosis. — When an exudate is situated else- 
where than in the broad ligament or retrocervically, there is formed 
a diffuse infiltration with many irregular extensions. When an 
exudate becomes smaller, the uterus resumes its normal position, 
the mass grows constantly harder, and most of it may be left close 
to the lateral pelvic wall. If so situated, the exudation is of a flat 
form, and when its connection with the cervix is lost may produce 
independent flat tumors situated on the posterior or lateral pelvic 
wall. 

There is some difficulty in diagnosing acute posterior parame- 
tritis in its retrouterine and retrocervical location from a peritoneal 
exudate. Posterior parametritis is situated under the Douglas 
peritoneum, extends further down, is nearer the vagina, and may 
extend into the rectovaginal septum, even half-way down toward 
the vulva. It has a sharp lower end and is not movable. It may 
extend far laterally and may surround the rectum like a ring, 
making its lumen smaller, as may be found on rectal examination. 
On rectal examination the mucosa is not movable. A posterior 
parametritic exudate soon becomes hard, and when it does extend 
upward is round on its upper surface through limitation by the 
Douglas peritoneum, and only extends up a certain distance on the 
posterior wall of the uterus. It must be diagnosed from a peri- 
toneal exudate in the cul-de-sac of Douglas. The latter is some- 
what movable. Its lower edge is round or oval or sharply outlined 
by the shape of the cul-de-sac of Douglas. It does not extend far 
laterally. It pushes the rectum to one side, as may be found 



PELVIC CELLULITIS AND PARAMETRITIS 513 

on rectal examination. It may extend up on the posterior uterine 
wall to the fundus. It is relatively soft and cystic. 

Symptoms. — When fresh, a parametritic exudate is soft and 
elastic. The symptoms are often relatively slight and may give 
the patient but little pain. The formation of pus is characterized 
by high temperature and great remissions. The pus may be foul, 
in which case the prognosis is worse. The pus may break of its 
own accord above Poupart's ligament or into the vagina, bladder, 
and rectum. When the exudate has become completely purulent, 
an incision should be made through the vagina, either into the 
broad ligament or into the posterior fornix. In some cases the exu- 
date breaks down into pus only in certain spots and the disease may 
be long-drawn-out, lasting for weeks or months. The proportion 
of the exudates which go on to abscess formation is small. These 
are generally situated in the broad ligament or retrocervically. If 
no pus degeneration takes place, the exudate may be completely 
resorbed or may leave sclerotic tissue behind. When the early 
edema subsides the parametric exudate feels hard and grows con- 
stantly harder, producing pain and discomfort according to its 
situation. 

Because of the hard character which parametritic exudates as- 
sume after the edema is gone, the older cases must be diagnosed 
from all hard tumors about the uterus. When situated in the 
broad ligaments or posterior to the cervix, they resemble in no 
slight degree fibroid tumors. In the broad ligaments a para- 
metritic exudate may be firm like a fibroid, but it is more closely 
connected with the lateral wall of the uterus and often has in- 
flammatory extensions, especially posteriorly into the vagina. 
Through the rectum a fibroid is felt to be round, while the para- 
metritic under-surface is flat and situated close to the pelvic wall. 
A fibroid is movable, while a lateral parametritic exudate is some- 
what movable only if it does not extend up to the lateral wall. 
The use of the sound shows the uterus elongated in fibroid. The 
symptom is pain. 

A small lateral parametritic exudate may resemble pyosalpinx, 

and it is often hard to tell whether we are dealing with parametritis, 

pyosalpinx, or both. Pyosalpinx lies higher, nearer the fundus, 

while the parametritic exudate may lie deeper, generally in the 

33 



514 MEDICAL GYNECOLOGY 

lower part of the broad ligament. The latter is near the cervix, 
may extend into the lateral fornix, is flatter and more diffuse. 
When the parametritis constitutes a parasalpingitis a diagnosis 
from salpingitis is almost impossible. 

Lateral parametritis may resemble hematoma of the broad 
ligament, but the latter is not so diffusely hard as is the exudate. 
Hematoma is more round and has fewer extensions. 

When existing on the right side, a parametritis must be diag- 
nosed from a perityphlitic exudate. The latter resembles those 
parametritic exudates in the broad ligament which have extended 
up toward the pelvic wall. In perityphlitis, however, there is a 
different history; the exudate is not connected with the uterus; it 
lies near the cecum and projects out more toward the abdominal 
cavity. 

Subacute Parametritis. — A subacute inflammation often oc- 
curs after labor or abortion, in many cases due to the presence of 
the gonococcus alone or associated with other bacteria or cocci, 
and frequently not recognized. This condition gives symptoms in 
the second or third week after labor. The patients do not improve 
in health, they have pain in the back, and at examination there 
is found, in addition to evidences of cervical catarrh, ectropion, 
etc., an induration or infiltration behind the cervix. This form 
involves the posterior parametrium and the uterosacral ligaments. 
In fact, involvement of the cellular connective tissue without 
cervical lacerations usually occurs in the posterior parametrium. 
In the early stages examination of the posterior parametrium shows 
a hard, diffuse infiltration like a fibroid, or sensitive edematous 
folds of Douglas. Very frequently there occurs after labor, 
abortion, or curettage a mild paraoophoritis or parasalpingitis 
involving the cellular tissue along the tube near the ovary and 
in the ligamentum infundibulopelvicum. It produces varicocele 
of the broad ligament. This condition, when sclerosis takes 
place, is productive of pain in the ovarian region which is affected 
by the position of the patient. This condition with alterations in 
the ovary produces by no means infrequently cases of ovarian ac- 
quired dysmenorrhea. 

There is a chronic, slowly progressive inflammation of the con- 
nective tissue, accompanied by sclerosis and thickening which is 



PELVIC CELLULITIS AND PARAMETRITIS 515 

known as parametritis retrahens. It is generally retrocervical, 
in the folds of Douglas, in the connective tissue under the Douglas 
peritoneum and surrounding the posterior fornix of the vagina. 
It may result from the above-mentioned subacute involvement 
post partum or after abortion which has originally produced a 
hard, diffuse infiltration behind the cervix and which has given 
symptoms. As a rule, this form produces no early symptoms 
which call for bimanual examination. It results from progressive 
infection of the connective tissue by a chronic cervical catarrh. 
In the early weeks after labor or abortion the posterior parametrium 
and the folds of Douglas may be extremely sensitive. This stage 
soon subsides and there results a progressive sclerosis and shorten- 
ing of the uterosacral ligaments. The only symptoms are back- 
ache and the subjective and objective symptoms of a cervical 
catarrh. In the course of years the latter undergoes improvement, 
and all that is finally seen is a sclerosed posterior parametrium. 

Parametritis retrahens is found in nullipara?, but is most 
marked in the women who have borne one or more children. 
Cervical catarrh seems to select the posterior parametrium. It 
does not form an acute swelling or pus, but simply produces an 
edematous infiltration which causes at first elongated, sensitive 
uterosacral ligaments, and so permits the cervix to descend and 
often allows a bulging into the vagina of the posterior roof or 
fornix. In nulliparae it simply forms a slow progressive infiltra- 
tion of the posterior, cellular connective tissue. The end- result 
is the formation, on one side or both, of a shortened sclerotic utero- 
sacral ligament with consequent limitation of mobility of the cervix 
and the production of a retrodisplacement with backache. 

Parametritis Atrophicans Diffusa. — There is a parametritis 
of more general nature which is called parametritis chronica atro- 
phicans diffusa (Freund), with which there is associated great 
atrophy of all the pelvic organs with early menopause and marked 
nervous symptoms. (See Hyperthyroidism.) 

Diagnosis. — If chronic or subacute parametritis involves the 
broad ligament, there is felt just above the fornix in the base of the 
broad ligament a sclerotic retracting band. The diagnosis is not 
difficult if the sclerosis is situated in the broad ligament, for we feel 
the infiltration lateral to the uterus, where it is easily palpated. It is 



516 MEDICAL GYNECOLOGY 

situated just above the lateral fornix in the base of the broad liga- 
ment. If the cellular tissue in the upper part of the broad liga- 
ment and the ligamentum infundibulopelvicum are involved there 
results a paraoophoritis, often with the symptoms of ovarian dys- 
menorrhea. 

When the fingers are passed high up into the posterior fornix in 
a case of posterior parametritis the normal elasticity is gone and 
pain is produced. An attempt to push the cervix up toward the 
symphysis discloses lack of mobility of the cervix. The sclerotic 
uterosacral ligaments are felt and pain is produced, often noted 
in the back and in the rectum. Examination per rectum discloses 
the same condition and infiltration is noted about it. Paramet- 
ritis must be diagnosed from perimetritic adhesions, though the 
combination of the two is frequent. The diagnosis is sometimes 
difficult. In the case of posterior parametritis we have two 
thick bands, representing the folds of Douglas, which pass out from 
the uterus at the level of the cervix, diverging externally and 
posteriorly. The space between the two is frequently thickened 
and banded. The uterus is often retrodisplaced. Mobility of 
the cervix is limited. Backache is a frequent symptom and 
is aggravated by examination. Perimetritic bands are to be 
diagnosed if we feel strands passing off from the fundus or from 
the whole posterior wall of the uterus, or if the ovaries are fixed. 
More than two bands exclude the uterosacral ligaments alone. 



TREATMENT OF PARAMETRITIS 

Not every acute parametritis ends in pus formation. Therapy 
consists in aiding resorption and, if this is impossible, in aiding 
suppuration, which is relieved by vaginal incision. Resorption 
occurs more frequently with post-partum exudates other than 
gonorrheal. The treatment of acute and subacute stages of 
parametritis is the same as that of acute and subacute salpingo- 
oophoritis. I have often seen cases after abortion and labor, 
particularly those coming on from ten days to two or three weeks 
after labor, heal and undergo resorption after weeks, and some- 
times months, of conservative treatment. The exudate is gelatin- 
ous or hard; it is diffuse. It gives no evidence to the touch of 



PELVIC CELLULITIS AND PARAMETRITIS 517 

breaking down into pus and is not associated with high temperature 
reactions. There is a minimum amount or else an absence of 
peritoneal irritation. Such cases of parametritis posterior, or espe- 
cially lateralis, as are, however, associated with high temperature 
reactions and evidences of marked peritoneal irritation are usually 
such as represent a combination of parametritis with salpingo- 
oophoritis and pelvic peritonitis. The size of the adnexal tumor 
is then hidden by the great involvement of the broad ligament or 
ligaments. Even here conservative treatment does well unless 
temperature reactions are high, pain is great, and the size of the 
exudate is continually increasing. Then vaginal incision removes 
the pus and hastens convalescence. Such cases, when treated by 
the abdominal route during the acute stage, readily prove fatal. 
The greater the localization of exudate in the connective tissue, 
and the earlier the occurrence of closure of the tubes, the less 
marked and the less dangerous is the associated pelveo-peritonitis. 

The treatment of parametritis following labor or abortion de- 
mands, of course, rest in bed, fluid diet, attention to the bowels, 
the application of the ice-bag or the ice-coil to the abdomen. Cool 
or tepid vaginal douches should be given several times a day of 
1 : 10,000 to 1 : 5000 bichlorid or i per cent, lysol. The formation 
of a large mass in the broad ligaments or in the posterior parame- 
trium, associated with continued temperature, increase in size, 
and pain, is relieved by incision and drainage through the vagina. 
Many of these cases in w T hich the exudate is hard and firm, and in 
which the temperature reactions are not high, may be brought to 
resorption without incision and drainage. Rest in bed plus the use 
of vaginal douches, plus the subsequent use of glycerin and gauze 
applied to the fornices, will bring about a fair restoration to the 
normal in many instances, even though this treatment takes weeks 
and not infrequently months. The end lesions in the majority of 
these cases are chronic parametritis, pyosalpinx, and perimetritic 
adhesions. 

The treatment of parametritis chronica, most frequently of the 
form of posterior parametritis, is essentially the treatment of the 
causal cervico-uterine inflammation or catarrh, and as such is 
fully described in the section on Endocervicitis. 

In the treatment of the chronic stage we are concerned with 



518 MEDICAL GYNECOLOGY 

involvement of the connective tissue associated with congestion and 
edema, or associated with a large exudate which has to go through 
resorption and sclerosis. The treatment of an exudate a week 
after the fever stage is passed consists of stimulating applications 
to the abdomen, hot douches of 4 quarts of water two or more times 
a day. If temperature returns and if bimanual examination gives 
evidence of softening and increase in size of the exudate, then hot 
douches and the hot applications should cease. If, however, re- 
sorption is taking place, and if fever is absent, abdominal and 
vaginal applications to produce hyperemia, followed at a later period 
by gentle massage after the hot treatment, are excellent. The result- 
ing hyperemia diminishes pain, stimulates the nutrition of the tissues, 
increases the power of resorption, and stimulates the lymph flow. 
If an exudate is situated in the cul-de-sac of Douglas, we may use 
thorough vaginal packing of the fornices and may apply a tight 
abdominal binder. In the later stages, salt baths, especially in 
the form of warm, prolonged sitz-baths, and of Nauheim baths 
are of value. Edema of the parametrium readily disappears under 
thorough vaginal packing of the fornices, carried out in the modified 
Trendelenburg position. (See page 99.) 

When sclerosis or parametritis atrophicans occur, with dislo- 
cation of the uterus and the adnexa, we must make use of hyperemia 
to alter the sclerosis of the connective tissue so that bimanual mas- 
sage may then restore the ligaments to their normal length. This 
demands hot sitz-baths and prolonged vaginal douches, very hot, 
to render the shrunken ligaments hyperemic, anesthetic, succulent, 
and stretchable. If this is followed immediately by vaginoabdom- 
inal massage, fixations can be loosened, adhesions can be stretched, 
and displacements can be corrected. The occurrence of fever 
or pain after such treatment demands the cessation of the treat- 
ment. (See pages 113, 115, 101, 102.) 

In the treatment of older cases Nauheim baths and salt baths 
are of value. The benefits of this method are not permanent, 
however, if during and after the baths mechanical stretching of 
the uterine ligaments is not done. 



PELVIC PERITONITIS; PERIMETRITIS 

Perimetritis is an inflammation of the peritoneum of the pelvis 
resulting in adhesions of the adnexa, intestine, or pelvic peritoneum, 
and especially of the uterus. It may be septic or gonorrheal, 
acute or subacute. It occurs most frequently as the result of the 
extension of a cervico-uterine inflammation through the tube or 
through the broad ligament lymphatics, sometimes from appendi- 
citis and peritoneal tuberculosis. 

If the tubes do not become closed and if pus is poured out, or 
if the infection rapidly involves the pelvic peritoneum, a peritoneal 
exudate results. Therefore in the acuter forms with the symptoms 
of peritonitis there results an accumulation of exudate of varying 
amounts in the cul-de-sac of Douglas, which can be readily made 
out only when under tension which occurs when the exudate 
becomes encapsulated. In the presence of much exudate the 
uterus is pushed forward and upward and a mass or tumor is 
felt back of the portio. When the exudate is encapsulated or 
organized its upper surface is not smooth or round, because it is 
formed by intestines. Often the inflamed adnexa are noted 
postero-lateral to the uterus, but the tubes and ovaries may be 
involved in the cul-de-sac of Douglas, with the peritoneal exudate. 
After an acute infection there may result simply adnexal tumors, 
more or less adherent to intestine, especially sigmoid, etc., which 
are usually situated postero-lateral to the uterus, or there may 
result adhesions which totally obliterate the cul-de-sac of Douglas, 
or there may be a fixed retroflexion of the uterus. 

There may be adhesions passing from the posterior wall of the 
uterus to the pelvic peritoneum. The lower part of the cul-de-sac 
of Douglas may be obliterated. The fundus may be fixed by 
stretchable bands. As a rule, the greater the involvement of the 
tubes, the greater is the adhesion of the uterus to the pelvic peri- 
toneum. 

In acute infections the tubes may become quickly closed and 
adhesions are present mainly about their outer ends. 

519 



520 MEDICAL GYNECOLOGY 

With the milder and the much more frequent forms of peri- 
metritis the results are different. There has never been an acute 
involvement, the condition being due to infection of the peritoneum 
by a catarrhal salpingitis, in the vast majority of cases gonorrheal 
in nature. The tubes have not been greatly inflamed, they have 
not become distended, have not dropped down by their own weight 
to the floor of the pelvis. The adnexa are involved in mild ad- 
hesions ; smaller or larger tubo-ovarian cysts may result and are 
often fixed close to the lateral pelvic wall. In many cases the 
adnexa may seem free on bimanual examination. 

We should make a distinction between the various localizations 
of adhesions after any form of peritonitis. Adhesions of the tubes 
to the posterior wall of the broad ligaments or adhesions of the 
outer ends of the tubes is always present with pyosalpinx or pyo- 
salpingitis. 

Many infections are of a mild nature; very little discharge pours 
out. It results in closure of the tube-ends or in adhesions of the 
tube-ends to peritoneum or peritoneally covered structures. A 
diffuse pelvic peritonitis has not taken place and the uterus itself 
may be free of adhesions of any form, i.e., a mild salpingo-oophoritis. 

If, without marked tubal involvement, the ovaries are involved, 
in adhesions, the term perioophoritis should be used. The uterus 
is free of adhesions. 

If the uterus on its posterior wall is held by adhesions, then the 
term perimetritis should be used. This implies the previous exist- 
ence of a pelvic peritonitis or a pelvic exudate situated in the cul- 
de-sac of Douglas, from which adhesions result. 

When the uterus itself is involved, we are really justified in speak- 
ing of perimetritis, though the term is often used to signify the 
various forms of adhesions in the female pelvis. 

If adhesions are present on its posterior wall the uterus is more 
or less firmly fixed, according to whether the adhesions are ex- 
tensive, long or short, dense or stretchable. Care must be taken 
not to confuse this condition with a retroflexion which is simply in 
contact with the posterior peritoneum and the rectum, and which 
may be difficult to replace. The uterus may be pulled back into 
retroversion or retroflexion by adhesions of the adnexa and by the 
sclerosis and shrinking of the ligamenta infundibulopelvica. 



PELVEO-PERITONITIS ; PERIMETRITIS 521 

Differential Diagnosis. — A differential diagnosis between 
parametritis and perimetritis is necessary. All lateral tumors 
which have a sharp, round, lower border speak against a parame- 
tritis. In the acuter stage a lateral parametritic exudate has an 
upper border of a rounded character, whereas a perimetritic con- 
dition has a diffuse upper border through adhesions of the intes- 
tines, while its lower border is sharp because it is outlined by the 
peritoneum of the cul-de-sac of Douglas. When perimetritic 
bands are felt through the posterior fornix, care must be taken 
not to mistake for them the thickened uterosacral ligaments. If 
more than two bands are felt, the condition is probably a peri- 
metritis. 

In many of these cases the uterus is retroverted or retroflexed, 
and the pain and other annoyances from which the patients suffer 
are attributed to the retrodeviation. In many of these cases 
there is a real inflammatory endometritis and erosions and cervical 
catarrh are present. For that reason, too, annoying symptoms 
in the way of pain, etc., are often attributed to intrauterine disease 
when peritoneal adhesions are the important pathologic factors. 
The diagnosis of peritoneal adhesions is one often made by exclu- 
sion. Perimetritis is often found on operation when not disclosed 
by bimanual examination. Adhesions cause much misery in 
some cases, while in other women extensive adhesions cause 
little or no annoyance. If the mobility of the uterus and its adnexa 
is limited, if repeated examinations produce the same pain by the 
same manipulations, we may presuppose either a parametritis 
or perimetritis. If we exclude a posterior parametritis because 
of its location, we are confronted with the diagnosis between para- 
oophoritis and sclerosis of the ligamentum infundibulopelvicum 
on the one hand, and perisalpingitis and perioophoritis on the 
other. With peritoneal lesions the tube and ovary are fixed. 

Treatment of Pelveo-peritonitis. — In the acute stage of 
pelveo-peritonitis rest in bed is of course essential. The rubber 
ice-coil is applied to the abdomen or else an ice-bag separ- 
ated from the skin by cloths. Cold sponging and the usual anti- 
pyretic mode of treatment should be instituted. 

In peritonitis the abdominal viscera and the omentum are en- 
gorged with blood, so that other parts of the body are deprived of 



522 MEDICAL GYNECOLOGY 

it. The proper mode of treatment is to replenish the empty body 
vessels, according to J. Berry. The effusion of serous fluid in the 
peritoneal cavity soon loses its germicidal power. Draining this 
fluid through operation leads to the effusion of fresh serum and the 
consequent increased destruction of bacteria. In the treatment 
of peritonitis with no collection of fluid in the peritoneal cavity 
there is a small amount of poison in the peritoneal cavity. Treat- 
ment then consists of free purgation by salines and the administra- 
tion of large quantities of fluid by the mouth, rectum, under the 
skin, or intravenously. A thorough cleansing of the intestines 
should be followed by very light diet, and the intestines should 
then be kept at rest. 

The head of the bed should be elevated. In a more diffuse 
peritonitis with distention of the whole abdomen the patient should 
be kept quiet and the stomach empty until the inflammatory proc- 
ess and exudates have become localized. With increasing accu- 
mulation of exudate, this should be removed per vaginam and the 
pelvis should be packed with iodoform gauze, according to the rec- 
ommendation of Pryor. In diffuse cases the sitting posture 
advocated by Murphy and the administration of salt solution by 
rectum every two hours are essential. 

In the subacute stage cold cloths changed every four or five 
hours, or else a Priessnitz bandage, should be applied and the 
bowels should be moved regularly by enemata. 

In the chronic stage warm and hot sitz-baths and warm full baths 
may be given. If exudative elements are present and temperature is 
absent, gentle but not too firm packing of the fornices with glycerin 
and gauze may be practised. In the presence of exudation, with 
fever absent, salt baths and the Nauheim baths are valuable. In 
old cases with the formation of adhesions a course of Nauheim baths 
associated with mechanical stretching of the adhesions is of great 
importance. Prolonged hot vaginal douches may be given as a 
preliminary to the bimanual stretching of peritoneal bands. 

However, the very large majority of cases of perimetritis 
occurring otherwise than in connection with abortion or labor 
are gonorrheal in origin, and the therapy of this form is described 
under that section. The end-results of a perimetritis, whether 
originally subacute or acute, are adhesions. These adhesions 



PELVEO-PERITONITIS; PERIMETRITIS 523 

exist in connection with a pyosalpinx or a salpingitis or a 
salpingo-oopohritis or tubo-ovarian cyst. The therapy, therefore, 
in these cases is surgical if pain persists. There is a large class of 
cases, however, in whom the adhesions about the tubes and ovaries 
or about the uterus are slight, stretchable, and often not made out 
on bimanual examination, but suspected because of the continuation 
of pelvic pain. A very few of these cases may be relieved of their 
annoyance by the use of hot vaginal douches, hot salt sitz-baths, 
Nauheim baths, and the vaginal therapy applied in the case of 
cervical catarrh. The application of a moist bandage at night 
sometimes affords relief. These slighter cases are frequently such 
as complain mainly of sterility, and they furnish the very largest 
proportion of the patients subjected to the so-called conservative 
operation on the adnexa. 



UTERINE RETRODEVIATIONS; RETROVERSIO FLEXIO 

In considering the supports of the uterus it is necessary to re- 
member that it is embedded in, and surrounded by, a large amount 
of connective tissue. Originally no pelvic fascia exists, since every 
muscle fascia is simply connective tissue which has been developed 
by tension and exercise. The pelvis in the fetus is filled with a 
non-differentiated connective tissue, forming a common support 
for the pelvic contents, uniting and dividing the different organs 
and permitting mutual movement, as well as uniting the pelvic con- 
tents to their surroundings. The peritoneum covers all the organs 
and lines the depressions, covering especially the uterus, the tubes, 
and the vessels which run to the uterus. The ligaments are simply 
peritoneally covered connective- tissue bands, surrounding the im- 
portant blood-vessels, and in them muscle fibers subsequently 
develop. The only ligament which is not formed passively is the 
ligamentum teres; it is preformed, while the others depend for 
their position upon the development of the uterus. While it is 
true that a lack of elasticity on the part of the uterine ligaments is 
a frequent cause of inhibition of uterine mobility, no one of them 
is an active factor in preserving the normal anteflexed position of 
the uterus. An important function of the parametria with their 
numerous muscle fibers is to preserve the cervix in an elevated 
position, and they are intended to give the uterus free play. Winter 
says : "The uterus may be pulled up to the symphysis, pushed into 
the sacrum, up to the lateral pelvic wall, or half-way up to the 
umbilicus; the portio may be pulled down to the vulva, and all 
this without pain." When the uterus is pushed up or pulled down, 
it returns to its normal place because of the elasticity of its sur- 
roundings. It belongs, therefore, to the most movable parts of 
the body, which fact speaks against an active influence on the 
part of the peritoneum or any one ligament in determining its 
position. 

In the adult woman the uterus lies between the planes of the 
pelvic inlet and outlet. In the standing woman, with the bladder 

524 



UTERINE RETRODEVIATIONS; RETRO VERSIO FLEXIO 525 

empty, the uterus is in a horizontal position. The cervix is nearer 
the posterior than the anterior pelvic wall, and lies in a plane pass- 
ing through both spinse ischiadicae. A perpendicular from the 
external os passes through the posterior portion of the perineum; 
from the internal os a perpendicular would pass through the middle 
of the perineum, while one from the anterior end of the corpus, 
which lies on a level with the fourth sacral vertebra, passes through 
the middle of the septum urethrovaginale (Waldeyer). It may be 
seen that, in this position, the cervix is much further back and but 
little lower than the fundus. The cervix enters into the upper end of 
the vagina at an angle with the latter, and the fixation of the vagina 
by the levator ani and the surrounding connective tissue, and the 
support furnished by the parametria, make the situation of the 
cervix a relatively fixed point. So long as the cervix is retained 
in this position and at this level, so long as the uterus, its "liga- 
ments," and the levator ani preserve their natural elasticity, so 
long will the forces of pressure and tension within the abdominal 
cavity preserve the uterus in its normal anteflexed position. 

Version implies that change of position of the uterus in which 
the cervix goes in one direction and the fundus in the opposite 
direction. A straight line of the uterus is preserved. If the 
fundus is further forward than is normal, the position is known as 
anteversion. If the fundus is further back, it is known as retro- 
version. In anteversion the uterus is straight, the cervix is high 
up, and points toward the sacrum. In lateroversion an old in- 
flammatory process in the broad ligament connective tissue through 
retraction pulls the cervix toward itself and the fundus goes in the 
opposite direction, or else the retracted connective tissue pulls the 
fundus toward itself. In retroversion the fundus is situated pos- 
teriorly near the sacrum, the cervix is more anterior, and the canal 
of the uterus is straight. 

. Flexion implies a change of position of the fundus in relation to 
the cervix with the formation of an angle at their junction. Ante- 
flexion, when pathologic, means that the angle at the internal os 
is sharper than normal. The cervix lies in the axis of the vagina 
and the fundus lies so closely on the cervix that the finger can scarcely 
enter the angle. Retroflexion finds the fundus in the hollow of 
the sacrum or in the cul-de-sac of Douglas. The cervix is nearer 



526 MEDICAL GYNECOLOGY 

the symphysis and the angle between the fundus and the cervix 
looks posteriorly. 

Retroversion is a step toward the formation of a retroflexion 
which takes place as soon as the region of the internal os becomes 
soft. In retroversion the fundus is near the sacral promontory. 
Gradations between this form of retroversion and the most acute 
retroflexion are called retroversio flexio. The cervix is nearer the 
symphysis (Fig. 75) and the anterior wall of the vagina seems 
shortened. In pregnancy in a retroflexed uterus the cervix is 
pushed up right behind the symphysis. With retroversio flexio 
there is a dislocation of the tubes and ovaries to the floor of the 
pelvis or into the cul-de-sac of Douglas if the ligamenta infundi- 
bulopelvica are lengthened. The nearer the cervix approaches 
the symphysis, the more it inverts the bladder wall. 

Retroflexion. — Under retroflexion (and retroversion) we must 
distinguish two forms — the congenital and acquired. Suffice it to 
say that in acquired retrodeviation the position of the uterus is due 
to such weakening of the parametria, especially the ligamenta lata, 
ligamenta inf undibulopelvica, and the uterosacral ligaments, that the 
cervix descends and moves forward toward the symphysis (Fig. 75). 
Therefore the fundus moves backward, for in the standing position 
the uterus is no longer horizontal. There results, then, a retro- 
version or retroflexion. Thus the primary descent of the uterus, 
or hystero ptosis, is the pathologic condition which causes the acquired 
retrodeviation. This condition of hysteroptosis is an important 
factor in the causation of numerous symptoms. It is by no means 
necessary that hysteroptosis should be complicated by a retro- 
deviation if the round ligaments and ligamenta infundibulopelvica 
are short, but acquired retroflexions and retroversions are the result 
of hysteroptosis. This discussion concerns mobile conditions, for 
a retroversio flexio fixata involves a peritonitic affection, i. e., a 
perimetritis. 

Congenital Retrodeviations. — It is interesting to consider the 
etiology of congenital retrodeviations, and to note the frequency of 
their occurrence. No further proof is then necessary to establish the 
fact that retroversio flexio per se is not a severe pathologic condition. 

In the embryo the Wolffian ducts take a course which follows the 
curve of the fetal body, and the ducts of Miiller make their way 



UTERINE RETRODEVIATIONS; RETRO VERSIO FLEXIO 527 

following closely the curved lines of the Wolffian ducts. The 
sexual strand, which includes the ducts of Wolff and the ducts of 
Miiller, at an early stage shows an angle which represents the 
situation of the external os of the cervix. In the future develop- 
ment of the embryo the proximal end of the sexual strand, the 
subsequent uterus, takes on a position of anteversion. This 
position is aided by the descent of the ovaries and the remains of 
the Wolffian body, and by the pressure of the intestines gradually 
filling with meconium. This pressure can be appreciated from 
the fact that on the ovaries and tubes impressions of the intestines 
may be recognized. This anterior curve of the uterus becomes 
gradually more pronounced, so that in some cases the corpus uteri 
lies horizontally. This second resulting angle represents the posi- 
tion of the future internal os. In embryos in the second half of 
pregnancy the uterus is usually anteverted, with a somewhat ante- 
flexed corpus. In the newly born the uterus rarely lies in the median 
line, but shows, as a rule, a deviation to one side or the other. 
It lies partly within the large pelvis, and the fundus projects above 
the inlet. It is therefore seen that anterior inclination of the uterus, 
with more or less anteflexion of the corpus, is the original position 
depending on certain processes of embryonal development (Nagel) . 
In the newly born fetus the intestinal tract and the urachus are 
thin tubes, while the genital tract fills out the remainder of the long, 
narrow pelvis, and the relatively large uterus lies mainly above the 
symphysis. The bladder is not yet unfolded, is long, and its 
fundus remains for a long time above the symphysis. With the 
gradual development of the bladder from its pyramidal to a round 
form, the pelvis also undergoes changes whereby it is no longer a 
straight continuation of the abdominal cavity, and its axis forms 
with the axis of the latter an angle which gradually becomes one of 
90 degrees. The pelvis becomes wider, and the urethra is no longer 
a straight continuation of the bladder, but forms with the long axis 
of the latter a curve which is concave anteriorly. The uterus, 
which in the fetal period filled out almost the entire straight, nar- 
row pelvis, is now only a small dependence on the posterior wall 
of the bladder, and, lying parallel to the main axis of the pelvis, the 
uterus takes on with the changed inclination of the latter, a still 
more anteverted position. The anterior inclination of the pelvis 



528 MEDICAL GYNECOLOGY 

becomes later still more pronounced, and is necessary for several 
reasons. One reason is that the bladder, when filled with fluid 
contents, would otherwise be carried as a burden by the elastic 
pelvic floor alone, and a full emptying of its contents would be 
impossible, for the lowest point of the pelvic floor in an upright 
position would lie lower than the external opening of the urethra. 
If, then, the pelvis did not take on a forward inclination, a con- 
dition like that in cystocele would result, for the bladder of the 
female lies deeper than that of the male (von Arx). 

The ovary descends from its point of origin at the sides of the 
upper lumbar vertebrae, and lies in the newly born on the psoas and 
the vasa iliaca externa. Its final position in the fossa ovarica is 
gained during childhood. The ovary is connected with the tube 
and the ligamentum ovarii proprium, but does not make the com- 
plete descent which the testicle does, although conditions are 
favorable, as is proved by those cases where the ovary or tube is 
found in the canal of Nuck. In the ligamentum genito inguinale, 
later the ligamentum teres, is a muscle homologous to the cremaster. 
The ligamentum suspensorium ovarii is the former plica phrenico- 
mesonephrica. 

Although embryonal processes bring the uterus into the position 
known as anteversio flexio, errors of development may be the cause 
of malposition. The formation of a short vagina, with an em- 
bryonally long cervix and small fundus, displaces the cervix so 
that it lies close to the anterior pelvic wall, and the action of ab- 
dominal pressure may then change this retroversion into retro- 
flexion. In the descent of the ovaries the presence of a short 
ligamentum ovaricopelvicum prevents the normal anteflexion of 
the uterus, so that, even if other factors produce no further change, 
a retroversion exists. Kustner finds a poorly developed corpus 
and a straight stretched retroverted uterus to be often present in a 
poorly developed fetus, while in a well- developed fetus a normal 
flexible anteflexed corpus is the general rule. Further, a fixation 
of the portio near the anterior pelvic wall, as a result of a poorly 
developed or short anterior vaginal wall, is productive of a mal- 
position of the uterus. Such conditions have been found frequently 
enough in the fetus to explain the origin of congenital deviations, 
so that embryonal development is responsible, not alone for the 



UTERINE RETRODEVIATIONS; RETRO VERSIO FLEXIO 529 

normal position of the uterus, but likewise for a large proportion of 
malpositions. 

Symptoms Attributed to Retrodeviation. — When we consider 
the numerous operative methods used in correcting retrodeviations 
of the uterus, and the general adoption of the Alquie- Adams opera- 
tion for the correction especially of mobile retrodeviations, it would 
seem that retroflexio versio uteri was of itself a condition demanding 
operative treatment. The symptoms attributed to retrodeviations 
are pain, leukorrhea, menorrhagia, reflex nervous symptoms, and 
sterility. The pain takes the form of backache, pain in the sacral 
region, headache, and pain in the abdomen and thighs. The back- 
ache is supposedly caused by pressure of the uterus on the nerves, 
acting through the intervening structures, or by the "exudate and 
adhesions which often accompany the displacement, or by circulatory 
interference which causes congestion and obstruction to the venous 
flow." Pressure on the rectum is supposed to cause constipation 
and pain. Headache accompanies the backache, especially if there 
is constipation. Leukorrhea is said to be often the only symptom 
for which the patient seeks relief. In other instances the only 
symptom is sterility. Frequency of urination is supposed to be 
caused by the pulling exerted on the anterior vaginal wall, on the 
urethra, and on the vesico-uterine fold. Menorrhagia or metror- 
rhagia is said to be present in some cases. Dysmenorrhea is also 
mentioned as a symptom and painful coitus is said to be present in a 
smaller number of instances. In some cases, even where there are 
no local symptoms, there are said to be general symptoms in the 
form of indigestion, nervousness, skin affections, general pain, eye 
ache, etc. Epileptiform attacks are mentioned as symptoms in 
a smaller number of cases. 

The annoyances so frequently found associated with these dis- 
placements, such as dysmenorrhea, sterility, metritis, endometritis, 
oophoritis, bladder, rectal, and nervous symptoms, have been 
viewed from two entirely different standpoints. The belief, on 
the one hand, is that complications alone are the cause of the symp- 
toms, and that the latter are not the result of the version or flexion. 
Proof is furnished by the fact that before puberty and after meno- 
pause deviations are found without annoying symptoms; by the 
further fact that the same symptoms are present with the above- 
34 



530 MEDICAL GYNECOLOGY 

mentioned complications without uterine deviations; and by the 
important 'fact that treatment of the complications brings about a 
cure. The opposite view is supported by the statement that treat- 
ment of the deviation relieves the annoyances, that close examina- 
tion shows the same symptoms to have existed before puberty and 
to continue after the menopause. The congestion of menstruation 
is considered, in the latter view, as being naturally an important 
element in increasing the annoyances during functional life. 

The fact that some cases exhibit no symptoms is explained by 
the varying nervous stability of patients, and by the statement 
that structural changes do not occur in the pelvic tissues in all cases. 
The failure to cure the symptoms after the retrodisplacement is 
corrected is explained by the fact that permanent structural alter- 
ations have occurred in the uterus, ovaries, and circulatory appa- 
ratus. The fact that the correction and cure of the complications 
often give relief, even if the malposition is not corrected, is ex- 
plained as occurring only in those cases where the complications 
are independent of the retrodisplacement or are the cause of it. 

The uterus is stated to have a most intimate connection with 
the cerebrospinal nervous system and with the solar plexus or 
abdominal brain of Byron Robinson. Reflex impulses are sup- 
posedly sent out by a retroflexed uterus to the abdominal viscera 
and the spinal cord, with resulting alteration in the functional 
activity of the intra-abdominal organs and the nervous system. 

The Dignity of Retrodeviations. — The objection which can 
be raised against the reports of those who attribute so many annoy- 
ances to retrodeviations, and who are in favor of operative treat- 
ment for that reason, is that they report large series of cases of 
retroversions and retroflexions without finding among them a 
large number of inflammatory and trophic alterations involving 
the uterus, tubes, and ovaries. It is impossible in a large series 
of cases not to have among them, in addition, a great number 
suffering from neurasthenia, from enteroptosis, from gastroptosis, 
and from pelvic, abdominal, and constitutional subinvolution. 
The backache so generally referred to the retrodeviation is usually 
due to hysteroptosis, gastroptosis, and most frequently to a pos- 
terior parametritis involving the uterosacral ligaments especially. 
Uterine leukorrhea is almost always an inflammatory condition due 



UTERINE RETRODEVIATIONS; RETRO VERSIO FLEXIO 531 

to catarrh of the cervix and uterus. While it cannot be denied that, 
associated with retroflexion, there may be annoyances due, however, 
to congestion, yet entirely too much stress is laid upon the influence 
of a version and flexion. Structural alterations of the lining of the 
uterus, of the wall of the uterus, and of the tubes and ovaries not 
the result of the retroversio flexio are overlooked. The vast ma- 
jority of cases with symptoms have lesions of these structures which 
are not always demonstrable by bimannual examination. 

I hold the opinion that uncomplicated retrodeviations cause no 
annoyance, that nervous or "reflex" symptoms do not result from 
retrodeviations, but are caused by other conditions standing in no 
direct relation to the retroflexion. Theilhaber finds that after re- 
position the subjective symptoms may disappear in a few days, and 
yet examination shows the uterus to be retroflexed in spite of the pes- 
sary. This proves that the pessary by relieving the primary hystero- 
ptosis relieves congestion, whether the uterus is retroflexed or ante- 
flexed. In a large percentage of cases the patients feel no improve- 
ment as regards their nervous symptoms and their local disturbances, 
yet frequently examination shows the replaced uterus to be in perfect 
anteflexion. He finds no improvement as regards fluor, in spite of 
reposition of the uterus, and the bleedings are diminished decidedly 
in very few cases. I do not believe that version or flexion of the 
fundus causes a congestion in the uterine circulation. Further, the 
symptoms in many cases of decided retroflexion are almost nil, while 
in innumerable instances a mobile uterus, but little displaced, shows 
the so-called "typical symptoms" of retroflexion. 

Frequency of Retroversio Flexio. — The examinations of 
Schroeder are of the greatest interest. To determine the 
frequency of retroversio flexio in healthy women, and in women 
not suffering from pelvic symptoms, he examined one hundred 
and eighty-four women six weeks post partum, eighty-two 
other patients complaining of no pelvic symptoms, and one hun- 
dred and forty-five general cases in the internal medical clinic in 
Konigsberg. His examinations of four hundred and eleven pa- 
tients included virgines intactae, nulliparae, and multiparas. In 
twenty-five virgines intactae without pelvic symptoms, he found a 
retroversio flexio ten times. In forty-nine nulliparae without pelvic 
symptoms he found fourteen cases of retroversio flexio. Three 



532 MEDICAL GYNECOLOGY 

virgines intactae with pelvic symptoms furnished one case of retro- 
versio flexio, while five times retroversio flexio was found in thir- 
teen nulliparae suffering with some pelvic symptoms, giving for 
ninety nulliparae thirty cases, i. e., 33 per cent, of retroversio flexio. 

One hundred and ninety-one multiparae without pelvic symp- 
toms furnished forty-two case of retroversio flexio, while twenty-nine 
retrodeviations were found in eighty-five patients acknowledging 
some pelvic symptoms, making a total of seventy-four cases of 
retroversio flexio in two hundred and seventy- six multiparae, i. e., 
26 per cent. 

At the menopause thirteen times retroversio flexio was found in 
thirty-eight patients without pelvic symptoms, while four cases were 
found in seven women with pelvic symptoms, giving seventeen 
retrodeviations in forty-five patients, i. <?., 27 per cent. 

In these four hundred and eleven women were found 18 per cent, 
of retroversions and 10 per cent, of retroflexions, giving a total of 
28 per cent. In three hundred and three patients without pelvic 
symptoms were seventy-nine retrodeviations, 26 per cent. In 
one hundred and eight cases with symptoms were thirty-nine retro- 
deviations, 36 per cent. It is to be mentioned that the symptoms 
were brought out only on special questioning. 

It seems, therefore, that 25 per cent, of women in general have 
retrodeviations of the uterus, of which two-thirds have retrover- 
sions and one-third retroflexions. Of the seventy-nine cases of re- 
trodeviation without pelvic symptoms, eight suffered from hysteria, 
three from neurasthenia, four from indefinite stomach symptoms, 
three from headache, and others from backache, dizziness, ischias, 
lumbago, etc. Of these seventy-nine cases only sixteen evidenced 
a more or less profuse menstruation, so that menorrhagia is not 
a result of retroflexion. 

Of thirty-nine cases of retrodeviations with symptoms, six 
nulliparae complained of some pain in the pelvis and back, with some 
disturbance (pain) during menstruation; five had aborted or had 
painful folds of Douglas; eleven had shortened, infiltrated, and 
painful parametria ; three had descended ovaries, and five descent 
of the anterior vaginal wall, giving twenty-four cases suffering from 
pain in the pelvis or back in whom causes other than the retro- 
deviation could be readily found. 



UTERINE RETRODEVIATIONS; RETRO VERSIO FLEXIO 533 

This review is quite sufficient to establish the fact that congenital 
retrodeviations are very frequent, and that congenital retroversio 
flexio usually constitutes a practically negative condition so far as 
local symptoms are concerned. Congenital retrodeviation is very 
frequently a stigma of general, constitutional inelasticity. 

How large a proportion of those retrodeviations, found on the first 
examination, during pregnancy or after pregnancy or abortion, are 
such congenital retrodeviations every one must decide for himself. 

The dangers of retroflexion and retroversion are the 
possible occurrence of incarceration of the pregnant uterus in the 
hollow of the sacrum, and future descent and prolapse of the non- 
pregnant uterus. For this reason retroflexion should be corrected 
in all cases and retroversion when there is evidence of lack of elas- 
ticity of the pelvic ligaments and pelvic connective tissue. Besides, 
correction of acquired retrodeviation lifts up the cervix and over- 
comes the hysteroptosis which is the etiologic cause, and so tends 
to relieve congestion and the sense of pelvic weakness and looseness. 

Relation to Pregnancy. — The course involved in pregnancy, 
however, is shown by the rare occurrence of retroflexio uteri 
gravidi incarcerata. Martin found in 24,000 gynecologic patients 
one hundred and twenty-one cases of retroflexio uteri gravidi, none 
of which caused decided annoyance. Of these, ninety-four came 
under observation with retroflexio uteri gravidi, while twenty- 
seven became gravid after they had been under observation. All 
these cases are probably pregnancies in a uterus already retro- 
flexed. The majority of such cases are not noted because prac- 
tically no symptoms are present. But incarceration may occur 
and therefore retroflexions should be corrected. 

Relation of Retrodeviations to Prolapse of the Uterus. — In 
the opinion of Kustner prolapse of the uterus results from a retro- 
versio flexio, while Veit holds that prolapse of the vaginal wall is 
an important factor in pulling the uterus out of its normal position. 
If the view of Kustner be strictly correct, the frequent occurrence 
of congenital retroversio flexio should be often followed and com- 
plicated by marked hysteroptosis, which, however, is not the case. 
When we consider how difficult it often is, in a vaginal hysterectomy, 
after opening the vesico-uterine plica, and after entering by incision 
into the sac of Douglas, to bring down the uterus, we may under- 



534 MEDICAL GYNECOLOGY 

stand how improbable it is that the descending vaginal wall alone 
can markedly affect the uterus, as Veit believes. Only when the 
parametria at the sides of the cervix and uterus are incised do we 
make a decided impression upon the uterus. 

Retroversion and the bringing of the uterus into the axis of the 
vagina does give opportunity for descent and prolapse of the uterus 
through the action of intra-abdominal pressure against the uterus 
which constantly pushes it down through the axis of the vagina, 
but an involvement of the ligaments about the uterus and of the con- 
nective tissue in the pelvis and about the vagina, and the lack of the 
pelvic and general elasticity, are the important preliminary factors. 

Acquired Retrodeviations a Stigma of General Inelasticity. 
— The changes and injuries resulting from pregnancy and labor 
have always furnished an important topic for the gynecologist. 
We hesitate now to refer many local or general symptoms to torn 
perineums or lacerated cervices. The movement has been higher 
up, and there too we no longer attribute to uncomplicated uterine 
versions and flexions the various physical and nervous annoyances 
supposedly caused through reflex channels. Numerous observa- 
tions have taught us that retroversions and flexions are either 
congenital or acquired. We know that such displacements may 
exist with or without a pathologic involvement of tube, ovary, 
connective tissue, or peritoneum. Yet lesions of these latter 
structures are often overlooked, because a displacement, when 
found, is so generally accepted as a causative factor in producing 
almost any complaint. 

On the other hand, daily instances come to notice of totally un- 
complicated versions and flexions with symptoms, and of others 
without symptoms. Very many more instances may be noted of like 
annoyances without uterine flexion or version. We now understand 
the annoyances accompanying cases of hysteroptosis which are 
not complicated by version or flexion; for the condition of sub- 
involution of the ligaments is the important factor. In very many 
instances such a local condition is only an evidence of the existence 
of an abdominal and general subinvolution. Frequently, movable 
kidney, gastroptosis, enteroptosis, etc., are found coexisting. 
Such patients often evidence a flabbiness and lack of elasticity 
which is by no means the result of the pelvic condition, so that we 



UTERINE RETRODEVIATIONS; RETRO VERSIO FLEXIO 535 

are compelled to consider the latter as a part of a general state. 
We are forced to the conclusion that non-inflammatory acquired 
displacements are the result of changes in the uterine ligaments, 
changes which include congestion and edema, and that such changes 
result first in a descent of the uterus, a hysteroptosis. The 
treatment of these associated lesions, and attention paid to the 
general condition of the patient, mark an important advance in the 
field of gynecology, and take us, in many instances, into the realms 
governed by the stomach specialist and the neurologist. We are 
getting over the error of following the principle of cum hoc, ergo 
propter hoc. If gynecology has involved numerous operative pro- 
cedures for the correction of uterine displacements, it has also 
opened the eyes of the medical man to the fact that careful and 
complete restoration to the normal is an essential in post-partum 
treatment, and that such care covers rather a period of ten weeks 
than of ten days. 

Hysteroptosis is associated with symptoms which may be under- 
stood when we consider the annoyances associated with gastro-enter- 
optosis, ren mobilis, etc. Above all, the predominant pathologic 
element is congestion and edema, not only of the uterus and adnexa, 
but especially of the connective tissue constituting the parametria. 

Post-partum Treatment. — In post-partum treatment, there- 
fore, great care should be taken to avoid hysteroptsis and a prob- 
ably resulting retrodeviation. Kustner advises an upright position 
within a few days after labor, believing that in this way, and through 
the consequent exercise given to the uterine ligaments, the normal 
position of the uterus is assured. An all-important fact is this, that 
involution should include not only a return of the uterus, but a re- 
turn of all the pelvic structures and the pelvic connective tissues, 
to a normal condition and normal position. This is especially 
important in cases in which forceps have been used. 

The pessary as a preventive of permanent post-partum hys- 
teroptosis is one of our most valuable adjuncts. The early and 
regular use of ergot is a most important factor if the patient cannot 
nurse her baby. The wearing of abdominal belts and binders is a 
most salutary aid. Above all, abdominal massage, exercises, and 
hydrotherapy should have a permanent place in this field, for noth- 
ing else so relieves congestion, increases elasticity, and aids invo- 



536 MEDICAL GYNECOLOGY 

lution. An additional important benefit is the restoration to the 
patient of a normal general circulation by a course of Nauheim 
baths. (See Subinvolution.) 

The Meaning of Retroversio Flexio. — Many retrodeviations 
are of congenital origin. Retroversio flexio per se is not a patho- 
logic condition responsible for marked local or general symptoms. 
The symptoms generally associated with retroflexion are not typ- 
ical, are present in innumerable cases without displacement, and 
are due to uterine, tubal, and ovarian complications. Where 
retroversio flexio without peritoneal, tubal, or ovarian complica- 
tions is associated with symptoms, the primary hysteroptosis and 
abdominal and constitutional subinvolution must be taken in con- 
sideration, always bearing in mind the influence of such physical 
states as gastroptosis and ren mobilis. Prolapsus vaginas and cys- 
tocele, while often associated with retrodeviations, are independent 
affections. Where retroversio flexio is accompanied by local symp- 
toms, these, if not due to myometrial, peritoneal, tubal, or ovarian 
complications, may be corrected in the vast majority of cases 
without surgical treatment, for pelvic congestion is the important 
alteration. If the use of the pessary causes a cessation of symptoms, 
a surgical operation which keeps the uterus in normal elevated 
position permits of removal of this support. 

" Reflex" or constitutional symptoms are not due to retro versio' 
flexio. 

Diagnosis. — The diagnosis of the position of the uterus is made 
by bimanual examination, supplemented perhaps by the use of 
the sound. The two fingers of the examining hand are introduced 
into the vagina and so turned that the palmar surfaces look upward 
in the anterior fornix. The other hand presses upon the abdomen 
in the median line between the umbilicus and the symphysis. The 
external fingers gradually exert gentle deep pressure through the 
abdominal wall, moving gently down toward the symphysis. 
The internal examining fingers press upward, and if the uterus is 
in normal anteflexion and if the bladder is empty, the fundus will 
be felt by the internal fingers or between the external and the in- 
ternal fingers (Fig. 5). 

If the uterus is anteverted or only slightly anteflexed, the internal 
examining fingers should be placed in the posterior fornix and the 



UTERINE RETRODEVIATIONS; RETRO VERSIO FLEXIO 537 

cervix should be lifted up toward the abdominal wall. The fun- 
dus is thus brought near the abdominal wall, and by the same ex- 
ternal manipulation as before described the fundus will be felt by the 
external hand, and pressure on it will be communicated to the ringers 
situated underneath the cervix in the posterior fornix (Fig. 8). 

If the uterus is retrorlexed, the internal ringers should be intro- 
duced into the vagina, into the posterior fornix, the thumb should 
be situated over the clitoris, the two last lingers should be folded 
on the palm of the hand and pressed against the perineum. The 
weight of the body leaning against the elbow of the examining hand 
exerts pressure which pushes the internal fingers toward the hollow 
of the sacrum (Fig. 4). A retrorlexed uterus will be then made out 
in the cul-de-sac of Douglas or higher up, and the cervix can be 
followed in continuity over the posterior angle into the fundus 
(Fig. 6). Pressure by the external hand on the abdominal wall be- 
tween the umbilicus and the symphysis increases the intra-abdomi- 
nal pressure and brings the fundus closer to the internal fingers. 

If the uterus is retroverted, the same manipulation should be 
used in passing the index and middle fingers high up into the 
posterior fornix. The external hand begins deep pressure at the 
promontory of the sacrum. In many cases then the internal 
fingers can pass along the cervix in a straight fine up to the fundus 
of the uterus. In other cases the external fingers can feel the fundus 
underneath the promontory of the sacrum. In many cases in 
nulliparae and in patients with tense or fat abdominal walls neither 
the external nor the internal fingers can feel the fundus. If the 
fundus is sought for in its normal anteflexed position and not felt 
(Fig. 7), and if it is not found retrorlexed, the uterus may be 
safely considered to be midway between these two positions, 
namely, in retroversion. 

Not alone for the purpose of placing the uterus in its normal 
position, but also as an aid in determining its position, as well as 
for the purpose of determining its mobility, the two following steps 
should be carried out in every bimanual examination: (1) With- 
out the aid of the external hand the internal fingers should be passed 
deeply into the posterior fornix and underneath the cervix, and 
the cervix should be lifted up toward the abdominal wall (Fig. 76). 
This puts the uterosacral ligaments and the posterior parame- 



538 MEDICAL GYNECOLOGY 

trium on the stretch. If then the middle ringer be passed from right 
to left in the posterior fornix, thickened uterosacral ligaments can 
be made out and any peritoneal adhesions on the posterior wall of 
the uterus can be felt (Fig. 77). At the same time the mobility of the 
uterus is defined and pain will be produced in the back and in the rec- 
tum in pathologic involvements of the posterior parametrium and 
greater pain with peritoneal adhesions. (2) After performing this 
manipulation the index-finger should be placed in the anterior for- 
nix and the middle finger high up in the posterior fornix (Fig. 78). 
The index- finger then pushes the cervix down and backward, which 
manipulation, when repeated several times with increasing firmness, 
always preceded by the lifting of the cervix, will bring a movable fun- 
dus further forward toward the symphysis (Fig. 79), especially if 
with retroflexion the middle finger at the same time pushes up on 
the fundus. If then the external hand be pressed deeply down 
toward the hollow of the sacrum behind the point to which the 
fundus is brought by this manipulation, and if then these fingers 
pull or massage the fundus toward the symphysis, almost every 
case of movable retroversion and retroflexion can be brought tem- 
porarily into normal anteversion or anteflexion (Fig. 80). If the 
external fingers be passed behind the uterus and the uterus cannot 
be brought forward or can be brought forward only with pain, we 
may presuppose the existence of peritoneal adhesions to the uterus 
or fixation of the tubes and ovaries with shortening of the liga- 
menta infundibulopelvica, or else we feel the retracted uterosacral 
ligaments. In such instances the middle finger of the internal 
hand being passed high up into the posterior fornix can make out 
the peritoneal adhesions, and if passed into the lateral fornices can 
make out the lateral or deep fixation of the tubes and ovaries. 

In doubtful cases, if there is absolute certainty that pregnancy 
does not exist, the sound aids, by the direction taken up by the tip of 
the sound, in determining the position of the fundus. The sound 
is not of great importance in determining the position of the uterus in 
uncomplicated cases, but is of great aid in the differential diagnosis, 
especially if a mass in the posterior fornix is thought to be a fibroid 
or a parametritic exudate or a pelvic hematocele or pelvic exudate. 

Treatment. — Since the danger of retroversio flexio consists in the 
frequent occurrence in multipara? of further descent and prolapse of 



UTERINE RETRODEVIATIONS; RETRO VERSIO FLEXIO 539 

the uterus, the uterus should be restored and kept in place in its 
normal position. In many cases the annoyances are not enough to 
justify operation or the patient refuses operation. Then the pessary 
should be used for months and years (Figs. 81, 82, 83, 84). 
The percentage of permanent cures by pessaries is small. Perma- 
nent results are obtained by the various forms of operation devised 
for retroversio flexio. In a certain number of cases, especially such 
as are known not to have been congenital, and which have developed 
after labor and which are seen before involution has taken place in 
some ligaments while others are in a state of subinvolution, in such 
cases the use of the pessary often brings about a permanent cure. 
In general the use of the pessary should be avoided when there 
are inflammation or adhesions about the uterus. There are some 
cases, however, in which, in spite of old adhesions of the adnexa, 
reposition of the uterus and the use of the pessary cause no dis- 
comfort. In such cases, which are rare, the use of the pessary is 
sometimes advisable. (See pages 89, 90, 90.) 

Retroversion. — Pessary treatment of retroversion is advisable 
to avoid the occurrence of retroflexion or of further descent of the 
uterus. In some cases it seems as if retroversion may contribute 
to the production of bladder symptoms. In mobile retroversion 
the patient should sleep on one side or on the other and as much as 
possible on the abdomen, and should avoid overdistention of the 
bladder. 

The treatment of fixed retroversion is the treatment of peri- 
metritis. The softening and loosening of adhesions is the impor- 
tant point. Intra vaginal pressure- therapy by glycerin and gauze 
packing is of value, especially if the adhesions on the posterior 
uterine wall extend to a fixed point, that is, the pelvic wall. Pro- 
longed warm and hot vaginal irrigations are used to soften the ad- 
hesions and to make the manipulation involved in bimanual at- 
tempts at stretching of the adhesions and correction of the retro- 
version less painful. The subjective annoyances are diminished 
by a course of Nauheim baths, which improve, in addition, the 
metro-endometritis. After a course of baths, stretching of the 
adhesions is much easier and this manipulation may be carried out 
during a course of the baths. If replacement is eventually possible, 
without pain and annoyance, a Hodge, Smith, or Thomas pessary 



54° MEDICAL GYNECOLOGY 

may be inserted, provided, of course, there is no marked or puru- 
lent involvement of the adnexa. 

Retroflexion. — Uncomplicated mobile retroflexion causes few or 
no general symptoms. When constipation, pain on defecation, 
dyspepsia, pain in the abdomen and back, and nervous symptoms 
are present, there is a natural inclination to decide that the position 
of the uterus must be corrected by operation. If, however, pa- 
tients are not benefited by local conservative treatment by prelim- 
inary correction with the pessary, it is hard to understand how oper- 
ation will correct the local and " nervous annoyances" of an uncom- 
plicated retroflexion. The general state, with which a pelvic ptosis 
or retrodeviation is associated, is one of constitutional inelasticity, 
splanchnic neurasthenia, or physical or mental asthenia. In some 
cases, it is true, general treatment fails to cure the patient entirely 
of her symptoms. It is probable that slight nervous annoyances 
are sometimes relieved by operation; for the rest, change of sur- 
roundings and the mental effect associated with an operative pro- 
cedure have a therapeutic value. In innumerable cases of retro- 
flexion there are unrecognized involvements of the tubes, broad 
ligaments, ovaries, and peritoneum. There is no doubt that in 
some patients the value of the pessary is due to or enhanced by the 
element of suggestion, i. e., by psychic influence. 

The uterus may be fixed by simple adhesions of its body or may 
be fixed through adhesions of the adnexa. Adherent retroflexion 
is ofttimes benefited by conservative treatment. The adhesions 
may be loosened and stretched by bimanual manipulation if no 
acute or subacute inflammations are still present about the uterus. 
If the bands are adherent to the pelvic wall, intra vaginal pressure- 
therapy by glycerin and gauze packing may be used. Prolonged 
hot vaginal douches of 112 F. and over prepare the tissues for 
bimanual treatment. Sclerotic bands are softened by this method, 
by hot sitz-baths, or by a course of Nauheim baths, and in this man- 
ner a retroflexion may be corrected after such treatment when 
usual ambulatory methods do not avail. If eventually the uterus 
can be brought into normal position, it may in some cases be 
treated like a movable retroflexion and held in normal anteflexion 
by the use of the pessary. 

Contact adhesion is to be treated by intra vaginal pressure- therapy 
before using a pessary. 



SUBINVOLUTION 

Uterine Subinvolution. — In pregnancy the uterus undergoes 
great hypertrophy, hyperplasia, and dilatation, associated with 
which is a stretching, a growth, and hyperemia of the broad and 
other ligaments, and of the various pelvic structures. In addition, 
there is hyperemia and congestion of the intra-abdominal organs. 
The intra-abdominal organs and the abdominal wall are subjected 
to pressure and stretching by the enlarged uterus. The vascular 
system is put to greater strain and a general state of hyperemia and 
altered metabolism results. During pregnancy we have an in- 
creased amount of watery elements of the blood, an increased 
proportion of fibrin, a diminished amount of albumin, an increase 
in the white blood-cells, a relative diminution in the number of red 
blood- cells and in the amount of hemoglobin. Before labor the 
temperature is higher in the last three months of pregnancy and 
there is an increase in the elements of the body, equal to one-thir- 
teenth of the body- weight. This increase is due to serous infiltra- 
tion and to the increased ability of the body to form organized 
tissue. Post partum, after a temporarily short rise, the tempera- 
ture is lower, the blood-pressure sinks and becomes normal on the 
sixth day. After labor there is a diminution of tissue change and a 
diminution in the amount of urine. 

The return to normal size, position, and condition (i) of the pel- 
vic structures, (2) of the abdominal organs and of the abdominal 
wall, (3) of the general circulatory apparatus and of the nervous 
system, constitutes involution. This a process which, for its 
completion, involves from three to six months, and which often 
never occurs. The failure of involution (subinvolution) may be 
due to frequent successive pregnancies. It may result after one 
labor. 

Simple Subinvolution. — During uterine involution fatty de- 
generation and atrophy of the muscle fibers occur, so that the muscle 
fiber may regain its normal dimensions. Failure of uterine involu- 

54i 



542 MEDICAL GYNECOLOGY 

tion is often due to congestion in the uterus or in the surrounding 
tissues. Displacement of the uterus is an important factor. 
Retained placental structures or retained decidua are contrib- 
utory elements. An important element is a poor general cir- 
culation. Uterine subinvolution is most frequent in women who 
do not nurse. Within a few weeks after labor the uterus is large, 
soft, and atonic. The patient has a sensation of weight in the 
pelvis; there may be profuse serous discharge, there may be 
menorrhagia, there is backache, and atony of all the pelvic struc- 
tures. If such a condition is allowed to persist, permanent 
changes take place. The same holds true of incomplete abortion. 

Subinvolution Fibrosis. — Under the peritoneal covering of the 
uterus is a membrane of elastic fibers. In addition, between this 
layer and the mucosa there are three other layers of elastic fibers. 
The elastic and fibrous tissues situated between the muscle bundles 
send branches between and around every muscle cell at right angles 
to the long axis of the cell, furnishing a framework or elastic sup- 
port which protects the fibers from overstretching and which per- 
mits their return to normal position on contraction. In pregnancy 
the elastic fibers undergo hyperplasia. The same changes take 
place in the parauterine and periuterine elastic fibers. When in- 
volution fails to occur and subinvolution persists for a long time, 
then, in addition to subinvolution of the muscle fibers, there occurs 
a marked increase in the elastic and fibrous connective tissue. 
There finally results an end-stage, which furnishes an enlarged, hard, 
brittle uterus, associated with which is an inelasticity of the blood- 
vessels and often an arteriosclerosis of the blood-vessels. In such 
a fibrosis there is a hyperplasia of the connective tissue, the elas- 
tic elements are thickened, and there is an increased amount of 
fibrous connective tissue. In the connective tissue around the 
uterus, in the broad ligaments, in the connective tissue between the 
bladder and the uterus, there are large dilated veins. In the broad 
ligaments there are plexuses of varicose veins. 

The tendency to the occurrence of fibrosis is increased by numer- 
ous labors occurring in rapid succession, by retroflexion occurring 
after labor, by inability to nurse, and by the performance of physical 
labor. As a result of the subinvolution and of the frequent preg- 
nancies such uteri are hard, enlarged, and firm. They grate on 



SUBINVOLUTION 543 

cutting. Such uteri have poorly conditioned muscle fibers, and are 
composed of much fibrous connective tissue and of numerous elastic 
fibers poor in contractile power. This uterine alteration is a very 
frequent cause of menorrhagia and also of metrorrhagia, and causes 
very frequently, toward the age of the normal climacterium, such 
a lack of contractile power in the uterus, with or without arterio- 
sclerosis of the vessels, that extremely profuse bleedings occur, for 
which, often enough, only a hysterectomy can be of any aid, for 
even curettage and atmocausis often fail to stop the bleedings. 

Inflammatory Metritis. — In contradistinction to such a simple 
subinvolution fibrosis, the uterus may be thickened, hypertrophied, 
sclerotic, or enlarged as a result of chronic inflammatory changes 
in the uterine lining and uterine wall. We are then dealing with an 
inflammatory end-stage of a real inflammatory metritis. As a rule, 
the distinction is not made between such alterations due to in- 
flammation and similar changes due to failure of involution on the 
part of a uterus The latter is generally considered under the 
heading of metritis. If the term metritis is to be used for inflam- 
matory cases, then the end- stage of subinvolution should be called 
non-inflammatory metritis or fibrosis uteri. (See Metritis.) 

Pelvic Subinvolution. — Subinvolution of the uterus itself is 
often only of secondary importance. Of far greater significance are 
the condition, size, and elasticity of the ligaments about the uterus. 
These ligaments, filled with elastic connective tissue and muscle 
fibers, are responsible in a very great measure for retaining the 
uterus in its normal position. The elastic fibers and the connective 
tissue about the vagina, bladder, etc., are of great importance in 
retaining these two organs in their normal situation. There oc- 
curs very frequently after one or more labors a failure in these liga- 
ments to return to their normal elastic condition. They remain 
elongated, inelastic, flabby, resulting in descent of the uterus, with 
or without retroversion and retroflexion, descent of the posterior 
wall of the vagina, descent of the vagina, etc. Of great importance 
in this connection is the condition of the levator ani muscles and of 
the muscles in the perineum. Much has been said of the effect of 
perineal laceration on the production of cystocele and descent of 
the uterus. If is a fact that even deep median laceration of the 
perineum which does not tear the insertion of the levator ani fibers 



544 MEDICAL GYNECOLOGY 

is not productive per se of descent of the vagina. That with lateral 
laceration of the levator ani such conditions do occur, can be 
readily understood, when we consider the insertion of the levator 
ani fibers to the rami of the pubis, their close anatomic relation 
to the lateral walls of the lower part of the vagina, and their inser- 
tion about the rectum, anus, and coccyx. Subinvolution or lacera- 
tion of these muscles, which form so important a part of the pelvic 
floor, is productive of a loosening from their situation of the bladder 
and vagina. But these alterations of position on the part of the 
bladder and vagina are as much due to atrophy or subinvolution 
of the connective tissues as to the injuries to the muscle fibers. 

Constitutional Subinvolution. — The condition which we 
finally observe constitutes a ptosis of the genital structures, to 
which the name of hysteroptosis may well be given. The name 
hystero ptosis is of special significance, for in the majority of these 
cases there is also a ptosis of other abdominal structures. It is 
natural to expect that the abdominal wall which does not return 
to a normal condition of elasticity, in which the recti are abnor- 
mally overstretched, in which the fasciae of the abdominal wall are 
overstretched, will fail to give proper intra-abdominal pressure 
and in this way fail to aid in sustaining the intra-abdominal 
organs in their normal position. But this is not the only important 
factor. The same failure on the part of the supports of the in- 
testines and stomach to return to their normal state of elasticity, 
the inelasticity or atrophy of the connective tissues, fibrosis of the 
elastic fibers in these structures, and the disappearance of fat about 
the kidneys, are important elements which cause enteroptosis, 
gastro-enteroptosis, and movable kidney. Probably half of the 
cases of gastro-enteroptosis have aretroverted or a retronexed uterus. 
With or without relaxation of the abdominal wall, with or without 
displacements of the intra-abdominal organs, there exists, too, for 
weeks, months, and often for years, a condition of intra-abdominal 
congestion in which the important blood- channels of the intra- 
abdominal cavity are loaded with stagnated blood, with conse- 
quent failure of proper blood-supply of these important secretory 
organs, and so resulting in altered functions of the stomach and 
intestine in particular. Associated therewith is a heavy dragging 
sensation, indefinite pains in the stomach and abdominal cavity, 



SUBINVOLUTION 545 

backache, feeling of weakness, indigestion, constipation, and mal- 
nutrition. 

This condition, while a local one, is markedly dependent on the 
lack of tone in the general circulator}' apparatus. This is a state 
which occurs not only in women who have been pregnant, but is 
also a general condition, often to be referred back to rickets in 
childhood, to the effect of various infectious diseases, to the in- 
fluence of chlorosis and anemia. A condition of this sort is very 
frequently acquired by women who have been pregnant, and it is 
of course especially aggravated in those patients in whom the eti- 
ologic factors just mentioned have been present and in whom 
there is a tendency to splanchnoptosis before marriage. There 
is an improper circulation of blood throughout the entire system. 
There is a failure of proper nutrition of the various organs of the 
body. There is improper oxidation of tissue, there is a sensation 
of general languor and lassitude, a lack of energy and tone. Com- 
bined with this lack of general circulatory tone is a parallel condi- 
tion in the nervous system. There is a physical and mental 
asthenia; in other words, neurasthenia is the predominant condi- 
tion. These patients suffer from palpitation of the heart, are weak 
and tired, suffer from indigestion and constipation, sleep is dis- 
turbed or irregular, there is restlessness. Patients cry easily and 
often show a lack of mental poise and stability. This condition 
may well be described as one of constitutional subinvolution. 

Splanchnic Neurasthenia. — "There are a large number of 
gastric and intestinal affections with bizarre and protean symp- 
toms designated as gastric and intestinal neuroses, but which in 
reality owe their genesis to the congestion of the intra-abdominal 
veins." "The greater the intra-abdominal tension, the less blood 
will be contained in the intra-abdominal veins." "This tension is 
largely dependent on the tone or tension of the abdominal muscles. 
Therefore, nervous exhaustion is a frequent cause of diminished 
tone of the abdominal muscles, which in turn diminishes intra- 
abdominal tension and conduces to blood stagnation in the veins 
of the abdomen." "Venous congestion interferes with a proper 
supply of arterial blood. The tissues and the organs bathed in 
pools of stagnant blood are practically in a state of asphyxia. The 
toxic products of digestion, which are normally removed by an un- 
35 



54^ MEDICAL GYNECOLOGY 

impeded circulation, have a specifically poisonous effect on the 
sympathetic system, a fact which is evident, owing to the frequent 
occurrence of depression, prostration, and nervous symptoms in 
nearly all disorders of the alimentary canal." " Gastro-intestinal 
disturbances, of whatever nature, seriously compromise the integ- 
rity of the nervous system, either by inducing neurasthenia or 
aggravating it, if it exists." 

"The entire question of splanchnic neurasthenia is one of ab- 
dominal plethora dependent on a variety of causes — notably dimin- 
ished intra-abdominal tension, insufficient lung development, a 
defective vascular apparatus. Splanchnic neurasthenia is one of 
the few forms of neurasthenia amenable to permanent cure, by 
measures having for their object relief of abdominal venous con- 
gestion." "In any splanchnic neurasthenia existing as an inde- 
pendent affection, the relief of symptoms almost positively follows 
relief of the venous abdominal congestion" (Abrams). 

There is certainly in many women a predisposition to the 
occurrence of abdominal or constitutional subinvolution. It is 
noted in women in whom there is a general inelasticity, an 
almost complete absence of fat, and a tendency to neurasthenia. 
Such women frequently have little energy. Even the greatest sub- 
sequent care fails to restore the various organs of the body to 
normal tone. This general state often occurs without the presence 
of an enlarged uterus. In fact, prolonged nursing is a frequent 
cause. 

Lactation Atrophy. — The changes occurring in lactation 
atrophy are a concentric atrophy of the uterus with a cavity of 
normal size but with a deficiency of muscular elements. These 
latter cases are frequently associated with small adnexa. The 
majority of nursing women who have a uterus under the normal 
size show all the evidences of poor nutrition, and especially laxity 
and flabbiness of the general body structures. In "prematurely 
aged women" lactation is poorly borne. It is in these cases that 
Frommell finds the greatest amount of uterine atrophy, and he 
supposes it to be an evidence that nursing deprives the body of a 
large amount of nutrition. 

Thorne considers lactation atrophy to be a reflex trophoneurosis, 
and believes that every nursing amenorrheic woman has a hyper- 



SUBINVOLUTION 547 

involuted uterus, without, however, an involvement of the ovaries. 
He acknowledges the frequency of anemic conditions associated 
therewith, but observes that those cases menstruating during 
nursing show no atrophy of the uterus. This associated men- 
struation is an evidence of sufficient ovarian stimulation. 

This condition of abdominal and constitutional subinvolution 
explains in many cases the relation so long and even still held to 
exist through reflex channels between cervical lacerations, cervical 
erosions, cervical catarrh, uterine catarrh, and especially uterine 
retroversions and flexions, on the one hand, and certain nervous 
phenomena on the other. In many instances the nervous con- 
dition is due to alterations in the ovary produced bytubo-ovarian, 
ovarian, and peritoneal complications, which complications are 
generally the result of an upward extension of a cervico-uterine 
infection. These ovarian lesions may be simply that mild infection 
of the follicles which leads to the formation of so-callled "cystic 
ovaries." The ovarian changes may be sclerotic in their character, 
resulting from mild tubal and peritoneal infecting lesions and 
from a mild paraoophoritis or parasalpingitis. The inflamma- 
tory changes in the ovary may be a chronic form, producing altera- 
tions not always easily classified, but interfering with the secretory 
work of these glands and causing ovarian dysmenorrhea. Aside 
from inflammation, congestion and improper circulation may 
interfere with the proper function of the ovaries. Hence pelvic 
and abdominal subinvolution may cause such functional ovarian 
changes as are symptomless so far as pain, or marked pain, is 
concerned. Even changes in the menstrual regularity or in the 
menstrual amount may be slight or absent; changes from the 
normal are often present. The important end-effect is an inter- 
ference with the proper secretory function of the ovaries. 

Hyperthyroidism. — We are often concerned with the care of 
patients who have grown nervous since child-birth. Of course, 
among such instances are nervous conditions due to various 
other causes and tendencies. A certain proportion of such ner- 
vous patients are, however, undoubtedly suffering from what is 
known as hyperthyroidism. Cases of hyperthyroidism may occur 
without local thyroid changes upon which we can place the tangible 
responsibility. These are due to a faulty relation between the 



54-8 MEDICAL GYNECOLOGY 

ovarian secretion, on the one hand, and the thyroid secretion, on 
the other. An altered or diminished ovarian secretion results in a 
relative increase of secretion from the thyroid. The consequent 
symptoms vary from nervousness and irritability up to symptoms 
which include sleeplessness, palpitation, rapid pulse, causeless 
diarrhea, flushes, etc., but without any exophthalmos, goiter, or 
marked tachycardia, or else with exophthalmos of varying degrees, or 
goiter more or less marked, or both. It is important to recognize 
the fact that Basedow's disease frequently occurs in an aberrant 
form, and that the cases shade down gradually to forms which, 
since exophthalmos, goiter, and marked tachycardia are absent, 
are to be called hyperthyroidism. Many such patients are found 
to have cystic ovaries, sclerotic ovaries, or other pathologic non- 
recognizable ovarian changes. Thus relative hyperthyroidism 
produces a group of symptoms like the nervous symptoms of the 
typical menopause or climacterium, except for the fact that flushes 
or flashes are less marked or absent. 

Post-partum Treatment and Prophylaxis. — A weighty ele- 
ment in the causation of these conditions of subinvolution and 
hyperthyroidism is failure of proper care in the post-partum stage. 
In the post-partum stage frequent examination of the patient should 
be made and the uterus and its ligaments should be restored to the 
normal. Abdominal massage should take care of the abdominal 
walls, deep abdominal massage should take care of the colon and 
intestines (Figs. 91, 92, 93, 94, 95). Tonics should take care 
of the blood-corpuscles and stimulate the circulatory apparatus, 
and Nauheim baths should restore the circulation and the nervous 
system to its proper balance. 

Within a few hours after labor the patient should be encouraged 
to spend very little time on her back, lying mostly on the right or left 
side. After the flow of milk has been established and the uterus is 
in the true pelvis, the patient should spend an hour every morning 
and an hour every afternoon lying flat on her stomach, and should 
sleep in this position a part of each night. A tight abdominal 
binder is not to be used, a comfortable binder being all that is 
necessary. Attention should be paid to avoiding distention of 
the intestines by gas. At all times the bladder should be emptied 
at intervals of six hours. From the fifth day on, patients should 



SUBINVOLUTION 



549 



use a commode at the bedside. Patients should be allowed to 
sit up on the fifth or sixth day for a short time, increasing the period 
daily so that the patient can be out of bed on the eighth to the tenth 
day, provided there has been no temperature reaction, even though 
slight. Toward the end of the second week or in the beginning of 
the third week, a course of baths should be begun containing at 
first salt, then salt and calcium chlorid, and finally carbonic acid 
gas should be added. (See Nauheim Baths.) Internal examina- 
tion should then determine the position of the uterus. If there 
is any appreciable retroversion or retroflexion, or a noticeable 




Fig. 123. — The best auto-exercise for getting the recti and abdominal muscles 
into good condition. The patient, with body held rigid and chest thrown out, 
raises herself slowly from lying to seated position and slowly then returns to the flat 
position. This is repeated for from ten to fifteen times morning and night, be- 
ginning on the twelfth to fifteenth day and continued for several weeks. 



tendency to descent of the uterus, a pessary should be introduced 
or else the vagina should be packed three times a week with gauze 
and glycerin, to give the uterus and the connective tissue elevating 
support. The return of the uterus to its normal size should be 
aided by the use of ergotol, 15 minims, three to five times daily, 
if a flow of milk has not been established. Lifting should be avoided. 
If the abdominal walls fail to promptly return to a tonic state, 
superficial and deep abdominal massage should be given and an 
abdominal belt should be applied and worn and exercises should 
be carried out (Figs. 91-96 inclusive, 123, 124). 



55o 



MEDICAL GYNECOLOGY 



The two best exercises are pictured in Figs. 123 and 124. 

Treatment should be devoted rather to the prevention of these 
conditions than to their cure, for if once the uterus undergoes a 
fibrotic change, if the ligaments of the pelvis and in the abdomen 
are not early restored to normal tone, treatment is then concerned 
with giving support by mechanical means to the uterus, to the 
abdominal walls, and to the intra-abdominal organs. When care 
of the general circulation is begun early and done systematically 
shortly post partum, its application is extremely efficacious in 




\ 



\ 



O 



Fig. 124. — The patient lies on her back, holds her legs together and straight, and 
then slowly lifts them, without bending the knees, to the perpendicular position, and 
then slowly lets them down to the flat position. This is repeated for from four to 
ten times morning and night after the exercise shown in Fig. 123 has been continued 
for a week, when it is continued in conjunction with exercise shown in Fig. 123. 



avoiding either constitutional subinvolution or hyperthyroidism. 
The longer this condition exists before treatment, the more diffi- 
cult it is to correct, for the patients lose their courage, acquire 
fixed ideas and phobias, and since the resulting condition came on 
after labor, are finally of the opinion that a genital condition is at 
fault, and feel certain that only an operation will be of any value. 
It is just in this class of cases that operations done for the correc- 
tion of displacements of the uterus, for the correction of cystocele 
and perineal lacerations, for the fixation of movable kidneys, etc., 



SUBINVOLUTION 55 1 

fail of their purpose, because such operations fail to cure the basic 
general asthenic condition of the patient. 

In the treatment of those cases coming to us with pelvic, ab- 
dominal, and constitutional subinvolution already established, at- 
tention must be paid to the pelvic congestion, to the bleedings, to 
the character of the uterine ligaments, to the abdominal wall and 
to the organs within the abdomen, to the general circulation, and to 
the condition of the nervous system. So far as the uterus is con- 
cerned, we must make use of the glycerin treatment with gauze, 
or of gauze packed into the fornices and followed later by the pes- 
sary, supplemented by the use of short hot vaginal douches. As 
regards the abdominal walls and ptosis of the intra-abdominal 
organs, we make use of abdominal massage, of diet for the correction 
of obstipation, of exercise directed to the strengthening of the ab- 
dominal walls, of an abdominal belt or Rose's bandage, and of 
hydrotherapy, most easily administered in the form of the Nauheim 
baths (pages 103, 108, 122, 337, 345, 379). So far as the use of 
drugs is concerned, those given for their effect on the nervous 
system and for their effect on the quality of the blood are indicated. 
For the former purpose a combination of bromid of strontium and 
sodium glycerophosphate is the best (p. 321). For the latter pur- 
pose a combination of iron, arsenic, and ovarin is of the greatest 
value, often combined with cascara (pp. 148-314). 

These cases are often associated with bleedings. They demand 
the use of douches, electricity, and sitz-baths for the production of 
uterine and pelvic anemia, and the drugs mentioned in the section on 
Uterine Bleedings. (See also Section on Myometrial Degeneration, 
etc., p. 575.) In giving the Nauheim baths, care is to be taken to 
avoid in these cases even a temporary exaggeration of the bleedings. 
Restoration of a normal circulation is followed by benefit, and 
most assuredly do the ovaries and the nervous system share in this 
nutritional alteration. 

Abrams finds the sinusoidal current (p. 351) of great value in the 
treatment of " splanchnic neurasthenia." 



MALPOSITION OF THE UTERUS AND VAGINA 

An altered position of the uterus implies a change in location of 
the entire, normally curved uterus with regard to its normal ana- 
tomic relations to the cavity of the pelvis. The entire uterus may 
be nearer the symphysis, or may be situated further back than nor- 
mally and nearer the hollow of the sacrum (retrodis placement). 
It may be descended or it may be prolapsed. 

Anteposition of the uterus is produced by a retrouterine tumor 
of the tube or ovary, by hematocele in the cul-de-sac of Douglas, 
or by a peritoneal exudate situated in the cul-de-sac of Douglas. 

Retroposition or retrodisplacement of the uterus means that 
the whole uterus is nearer the posterior pelvic wall, that the fundus 
is in the hollow of the sacrum under the sacral promontory, and 
that the normal anteflexion of the uterus is retained. The uterus 
may be pulled back into this position by adhesions in the cul-de-sac 
of Douglas resulting from hematocele or from a pelvic peritonitis, 
but occurs most frequently through the sclerosis and retraction of 
the uterosacral ligaments and the posterior paramentrium produced 
by a posterior parametritis. The important symptom is severe 
backache. 

A lateroposition of the uterus means that the uterus is pulled 
or pushed toward the right or toward the left pelvic wall. This is 
produced by tumors of the adnexa, especially by intraligamentous 
tumors. A recent intraligamentous hematoma or a parametritis 
with exudation will push the uterus toward the other side, whereas 
an old sclerosing parametritis may pull the cervix or the fundus 
toward its own side. 

Hysteroptosis. — A certain degree of ptosis of the uterus pre- 
cedes the production of an acquired retroversion or retroflexion. 
Ptosis of the uterus with descensus vaginas means that the anterior 
wall of the vagina or the posterior wall of the vagina or both walls 
are descended in association with a marked descent of the uterus. 
If the uterus is descended down to the vulva, such a hysteroptosis 
is called a descensus, and implies a preliminary retrodeviation. 

If the uterus extends beyond the vulva, the condition is called 
a prolapse. 

55 2 



MALPOSITION OF THE UTERUS AND VAGINA 553 

Primary descensus and prolapsus uteri are due to inelasticity 
and stretching of the ligaments connected with the uterus and to 
inelasticity of the pelvic connective tissue. 

In the primary form the upper part of the vagina preserves its 
roof or fornix anteriorly, posteriorly, and laterally and the cervix 
is not elongated. In the secondary descensus associated with elon- 
gation of the cervix there is inelasticity of the uterine ligaments, and 
especially inelasticity of the connective tissue about the vagina. 
The vaginal walls descend, pull on the uterus, pull it down, and 
elongate the cervix. The uterus when measured by the sound is 
increased in length, the rounded roof of the fornix is absent, and 
the upper part of the vagina is angular and hugs the cervix closely. 

Kiistner believes that the uterus cannot leave the pelvis or the 
vagina if situated in physiologic anteflexion. He considers that 
it must first come into a position in which its axis has almost the 
same direction as that of the vagina. A retroversion or slight retro- 
flexion then permits abdominal pressure to cause a descensus of 
varying degrees. The nearer the portio approaches the vulva, the 
more is the vaginal canal shortened, and so finally lies outside the 
vulva as a prolapsus vaginae, a condition so often combined with a 
retroversio flexio. He thus considers prolapse of the uterus and 
vagina to result after the retroversio flexio. 

Prolapsus Vaginae. — Any pronounced descent of the uterus is 
accompanied by a descent of the vault of the vagina. It must be 
noted that in addition to this descent of the vault of the vagina, even 
though slight, the lower end of the vagina often protrudes with a 
descensus uteri. 

Although the presence of a retroflexio versio may make it easier 
for a prolapse of the vagina to occur, yet Veit considers prolapse of 
the vagina an independent affection, and considers the vaginal 
wall to be the factor which pulls the uterus out of its normal posi- 
tion. Against this latter view of the cause of descensus uteri in 
many cases it may be said that anatomic considerations and surgical 
experience prove that the parametrium, when normal, is of such a 
character that a prolapse of the vagina is, of itself, incapable of 
pulling down or displacing the uterus. 

Descensus uteri and prolapse of the vagina, though often com- 
bined, are two independent affections. The fact that the two are 



554 MEDICAL GYNECOLOGY 

often coexistent is no proof that one is always associated with the 
other. Either may occur independently. They are due to the 
same cause, i. e., injury during labor, and subinvolution. Atrophy 
or degeneration of certain tissues about the vagina may cause the 
mucous membrane to lie in folds, as is so frequently the case at the 
climacterium, when there is a resorption of fat and a change in the 
connective tissue, a disappearance of active elastic fibers, and a 
loosening of the various relations. Such changes not infrequently 
occur, too, in younger women. In addition, there is a frequent 
congenital malformation, whereby the lower end of the vagina, 
the hymen, and the external genitalia, extend beyond the rami of 
the pubis, constituting a congenital elongation of the vagina. This 
form, mild in nulliparae, is often greatly increased in multipara?, and 
constitutes a true prolapsus vaginae. Such a condition of the 
lower half of the posterior vaginal wall, due to perineal laceration, 
is not a rectocele unless it contains a diverticulum of the rectum. 

TREATMENT 

A certain degree of hysteroptosis is responsible for the acquired 
forms of retrodeviation. The cervix has descended downward 
and forward in the pelvis, has approached the symphysis, and the 
fundus falls backward, since the uterus is no longer horizontal 
when the woman stands up. The pessary corrects a retroflexion 
or retroversion because it holds the cervix high up and far back 
toward the sacrum, hence the fundus readily stays forward. 

There are many cases of hysteroptosis without retroversion or, 
especially, retroflexion. In spite of descent of the cervix the 
fundus is held forward by the round ligaments, the broad ligaments, 
or by its own rigidity at the internal os. There is ptosis, but no 
version or flexion toward the sacrum. One hundred women with 
an uncomplicated hysteroptosis of this type will furnish just as many 
cases of backache, hypersecretion, and "reflex symptoms" as will 
one hundred cases of uncomplicated retrodeviations. The retro- 
deviation of the fundus per se is of no moment in the production of 
symptoms. Hence some of these cases of hysteroptosis are greatly 
benefited by treatment which lifts up the uterus, which diminishes 
uterine and pelvic congestion, and which involutes the ligaments. 

Intravaginal pressure-therapy and the pessary are important. 
General treatment is essential. (See Subinvolution.) 



MALPOSITION OF THE UTERUS AND VAGINA 555 

In the more severe degrees of hysteroptosis with which a retro- 
deviation is always associated, a pessary may lift up the uterus 
and hold it in place provided the vaginal walls are not too relaxed 
and if the levator ani muscles preserve some of their elasticity. 
In some cases round rubber or wooden rings or the Menge pessary 
(Fig. 86) serve to support the uterus and relieve the dragging 
sensation. Rest in bed and thorough packing of the vagina with 
gauze and glycerin will have a beneficial effect on some cases and 
will restore them to a state where pessaries will be of aid. 

Otherwise the ideal operation for the correction of descensus 
uteri and prolapsus uteri in women who are to bear no more chil- 
dren is vagino-fixation as practised by the author, an especially 
valuable operation because it permanently corrects the associated 
cystocele or prevents its occurrence if not present with hysteroptosis. 

Retrodisplacement is a frequent malposition of the uterus. 
Occasionally it is a congenital condition, and if it causes annoyance 
it should be put into normal position by a pessary after preliminary 
treatment by intravaginal pressure-therapy to first lengthen the 
congenitally short uterosacral ligaments. In these cases the vagina 
is a very long one. 

Acquired retrodisplacement is the result of a sclerosing posterior 
parametritis, and among other pains, felt during or between men- 
struation, is the constant backache and discomfort on defecation. 
The anteflexed uterus lies in the hollow of the sacrum. These 
cases can be much benefited by repeated packings with glycerin 
and gauze packed thoroughly into the posterior fornix and left in 
place for twenty-four hours. Prolonged hot vaginal douches are 
taken daily and a twenty-minute hot sitz-bath is taken at night. 
These soften and make succulent the sclerosed connective tissue 
and the uterosacral ligaments. Later on, vagino-abdominal massage 
is done gently and steadily for two to five minutes twice a week, 
followed by the introduction of glycerin and gauze (Figs. 89, 90). 
In the course of a few weeks the uterus is made so freely movable 
that a pessary can be introduced and the uterus is held in normal 
position. Such cases are frequent and furnish a class of patients 
whose symptoms can be markedly relieved. This acquired con- 
dition is the result of an old, very long- continued cervical catarrh. 
With this condition a large hypertrophied cervix is often present. 



VAGINAL HERNIAS 

While they do not constitute affections which markedly affect 
the comfort of the patient, vaginal hernias, especially the two 
common forms {cystocele and rectocele), are often complicated by 
annoying symptoms, conditions, and states. The origin, prophyl- 
axis, and importance of vaginal herinas are not subjects of general 
agreement. Dependent as they are on the injuries and lesions 
consequent on labor, and evidencing their presence, as a rule, long 
after the same, various views as to the origin of anterior vaginal 
hernias have been based on the presence of uterine displacements 
and perineal lacerations, while theories of an uncertain character 
have served to settle the etiology of rectocele. 

The connection between perineal lacerations and rectocele, for 
instance, is generally discussed without due attention to the im- 
portant muscular lesions which produce these affections. There- 
fore, the frequency with which decided perineal lacerations are not 
followed by rectocele must have been noted by all close observers. 
For a long period the value of the perineum and the relation 
of its injuries to the condition known as cystocele have also been 
erroneously estimated. Most striking, from a clinical aspect, is 
the disproportion between the evident affection and the symptoms 
in numerous cases. External injuries afford no criterion as to the 
state of the deeper tissues of the pelvis or as to the annoyances 
the patient feels or may feel later on. The so frequent correction 
of these external hernias without the attention to pelvic lesions, the 
correction of uterine malposition without preliminary or sub- 
sequent treatment of the other pelvic states, which may not be 
characterized by digitally evident lesions, are therefore not always 
attended with results satisfactory to the patient. 

Just as hysteroptosis and prolapsus vaginae should be con- 
sidered affections independent of each other, although their 
etiology is the same, so prolapsus vaginae and the various forms 
of vaginal hernia should be differently viewed. The name 

556 



VAGINAL HERNIAS 557 

cystocele is generally applied to any protrusion of the mucous 
membrane of the anterior vaginal wall extending through the ex- 
ternal opening of the vagina, and which is either externally visible 
or which actually extends beyond the external genitalia. Such a 
condition, however, may be a congenital elongation of the vagina, 
a prolapsus vaginae, or a true cystocele. A close distinction is 
often not made and the two latter terms are sometimes applied 
indiscriminately. 

Anatomic Relations of the Vagina and Bladder. — Pro- 
lapsus vaginae and cystocele must be distinguished, for a cystocele 
constitutes simply a hernia of the bladder, as may be seen from a 
study of the anatomic conditions. Cystocele, too, is independent 
in its origin of uterine displacements. I am reminded of an old 
case of decided cystocele, in a woman fifty-five years old, which had 
pulled down the anterior fornix, so that this area, too, was a part 
of the cystocele covering. Tugging had elongated the anterior lip 
of the cervix at least one inch, and yet the uterus was in normal 
position and not descended. On the upper portion of the cysto- 
cele wall intestines could be felt, for the bladder connections with 
the cervix were entirely loosened. No rectocele was present and 
no descent of the posterior or lateral vaginal walls. 

We may have: (i) Cystocele with a normally situated uterus; 
(2) cystocele with a hysteroptosis; (3) cystocele with a retro- 
deviated uterus; (4) cystocele with a hysteroptosis plus a retro- 
deviation of the uterus. In addition, we may have cystocele 
with or without rectocele. 

The diaphragm of the pelvis is formed of the levatores ani and the 
musculus coccygeus, and is perforated by the rectum, the vagina, 
and the urethra. The rectum is the only one of these three canals 
really united to the levator ani. 

A muscular connection for the urethra and the vagina begins 
only when they pass through the trigonum urogenitale. 

The vagina at its outlet is surrounded by the musculus bulbo- 
cavernosus, which is attached posteriorly to the centrum perineale, 
and which anteriorly surrounds the corpus clitoridis. It is called 
the constrictor cunni. The pars anterior of the musculus trigoni 
urogenitalis is situated at the sides of the vagina, its fibers crossing 
anteriorly in front of the urethra, forming the compressor urethrae. 



558 MEDICAL GYNECOLOGY 

The pars media of the muscle consists of circular fibers, arranged 
about the vagina and the urethra. Higher up the fibers do not 
unite behind the vagina, but do unite about the urethra alone. 

The vagina penetrates the diaphragm of the pelvis in the middle 
of its own length. On its upper surface is the vesicovaginal sep- 
tum of connective tissue and its close connection with the urethra, 
the urethovaginal septum. Laterally it is bounded by a vessel 
plexus and connective tissue and by the levatores ani. Only at its 
lower end has it the above-mentioned intimate relations with muscle 
fibers. The important relations of the vagina are with the trigonum 
urogenitale and its muscle, the perineum, the septum urethrova- 
ginale, and especially with the levatores ani. 

The urethra in its lower two-thirds is firmly connected with the 
vagina. Laterally, on either side passes the levator ani. Lateral 
to it and surrounding it are the musculus trigoni urogenitalis and 
the musculus bulbocavernosus. Anterior to the urethra are the 
plexus venosus pudendalis and the trigonum urogenitale. 

The bladder in the newly born is a tube narrowed above into the 
urachus, which, with the umbilical arteries, holds the bladder 
close to the anterior abdominal wall. In adults, after descent of 
the bladder, spaces are formed which are filled with fat. Before 
puberty the fundus of the bladder rests upon the cervix and the 
upper third of the vagina. la adults only the trigonum vesicae 
rests on the vagina and probably upon the portio. Because of the 
absence of the prostate, the orificium internum urethrae lies deeper 
than in the male. Below the bladder are the symphysis, a body 
of fat, the pudendal plexus, and the urethra. Below and lateral 
to the bladder are connective tissues of the parametrium and the 
muscles of the pelvic floor, especially the levatores ani. In front of 
the bladder is found the fascia vesicae, and the cavum Retzii filled 
with fat, in front of which is the transversalis fascia covering the 
posterior surface of the symphysis. 

The bladder is held in place by the peritoneum, the fascia vesicae, 
the ligamenta umbilicalia, the musculi pubovesicales, and the 
liagmenta pubovesicalia. It is supported by the vesicovaginal 
septum of connective tissue, connective tissue, fat, and the levator 
ani muscles. From a study of these relations (Waldeyer) it may 
be seen that the vagina, except at its outer end, is simply surrounded 



VAGINAL HERNIAS 559 

by connective tissue. The only thing which prevents the vagina 
from being pushed down by abdominal pressure is the action of 
the levator ani muscles and the character of its connection with the 
surrounding connective tissues. Atrophy or degeneration of these 
tissues causes the mucous membrane of the vagina to lie in folds, 
as is so frequently the case at the climacterium, and in younger 
women, too, when there is a resorption of fat, a change of connec- 
tive tissue, a disappearance of active elastic fibers, and a loosening 
of the various relations. Such a condition affects the lateral wall 
of the vagina, primarily, to only a slight extent. It is only affected 
secondarily after prolapse of the anterior wall. 

After pregnancy and labor there is a disturbance in the anatomic 
condition of the various structures of the pelvis. The levatores ani 
and constrictor cunni are decidedly stretched and often torn, and, 
as a result, the narrow vagina is widened and the original narrow 
slit becomes a large canal. There is a disappearance of fat and a 
flabbiness and edema of the connective tissues and of the liga- 
ments — that is, subinvolution is observed. Such a condition in the 
anterior wall, almost always a sequence of labor, permits the filled 
bladder, loosened from its fastenings, to descend and produce a 
protrusion of the weakened anterior vaginal wall through the in- 
jured levator ani and the connective-tissue floor, which, normally, 
support it in place. The lesions are exactly the same as occur 
in hernia in the linea alba of the abdominal wall. 

Cystocele. — This tendency to flabbiness of the connective tissues 
is a frequent result of labor, and occurs most frequently in individuals 
who exhibit this tendency as nulliparae. Gastroptosis, gastro- 
enteroptosis, and ren mobilis have been found to occur frequently 
in rachitic and neurasthenic individuals. I have referred to such 
cases evidencing even as nulliparae a decided tendency to a descent 
of the uterus and to flabbiness of the pelvic structures, and have re- 
ferred to the frequency of their combination with abdominal ptoses. 
To this descent of the uterus, of whatever grade, because of its 
etiology, I have given, in harmony with the conditions existing in 
the abdomen, the name hysteroptosis. These patients especially, 
as well as others, show after labor every evidence of subinvolution, 
even if the uterus returns to its normal size. The ligaments of the 
pelvis and of the abdomen are loose, edematous, and flabby, and 



560 MEDICAL GYNECOLOGY 

the muscles of the pelvic floor evidence the same characteristics. 
Most important, there has been an injury to the levator ani muscles 
and the musculus trigoni urogenitalis (especially in instrumental 
delivery) or else these muscles are subinvoluted. Naturally enough, 
as a result of the descent of the uterus, retroflexio versio is frequently 
present, and for this reason main attention has been paid to the dis- 
placement, and it has been considered the etiologic factor in causing 
the subsequent changes, while the elements of local subinvolu- 
tion and atrophy and predisposition to inelasticity and injury to 
the levator es ani have been overlooked. 

With such cases, as well as with any other case of subinvolution 
of the pelvic structures, if there has been a stretching of the levator 
ani or a rupture of the same, a space is immediately formed which 
furnishes opportunity for descent of the bladder through pressure 
upon the weak anterior vaginal wall. The edematous swelling of 
the urethral prominence and its protrusion into the vagina are the 
first evidences. Added to this, the same conditions of edema or 
atrophy exist in all the connective-tissue elements uniting the blad- 
der with the symphysis and abdominal wall, with consequent loss of 
their support. The erect position, abdominal pressure in emptying 
the bladder and in defecation, plus the abdominal condition, result 
eventually in a descent and hernia of the bladder. Perineal lacer- 
ation with the supposed resulting absence of support of the anterior 
vaginal wall by the posterior wall has nothing to do with this result- 
ing hernia. 

In catheterizing these cases of true cystocele it is perfectly evi- 
dent that the bladder fills out the dilatation in the anterior wall, 
and the bladder is no longer supported by the levatores ani of the 
two sides, which, normally, are close together along the urethra and 
the lower portion of the vaginal wall. In cystoscoping these cases 
it is readily seen that the bladder constitutes a hernia. It is not the 
descent of the vaginal wall which brings the bladder with it, but 
the weight of the filled bladder which dilates and stretches the 
subinvoluted anterior vaginal wall. I have, in numerous instances, 
found the uterus absolutely normal in situation and pulled down 
into the vagina only with difficulty, and yet the cystocele was pro- 
nounced. 

Proof of the fact that the weight of the filled bladder is the cause, 



VAGINAL HERNIAS 561 

is shown by the frequent recurrence of a cystocele after anterior 
colporrhaphy, even though, in addition, a high perineum is re- 
stored by plastic operation with a resulting narrow vaginal canal. 

Enterocele; Rectocele. — Out of the broad general class, pro- 
lapsus vaginae, we must remove the following forms of vaginal hernia : 
(1) The most frequent, involving the lower half of the anterior 
vaginal wall, the so-called prolapsus vaginae anterior, or, better and 
truly speaking in most cases, cystocele. (2) Prolapse of the upper 
third of the anterior vaginal wall through descent of the intestines 
(rare) . It is possible only when the union between uterus and blad- 
der has been disturbed. This condition constitutes an enterocele 
vagina anterioris. (3) Prolapse of the upper portion of the posterior 
vaginal wall through a descent of the intestines, or enterocele vagince 
posterioris. Here the uterus and the lower half of the vagina may 
not be affected as regards their position. The upper part of the 
posterior vaginal wall, however, is pushed down by the intestines 
in the sac of Douglas. (4) A dilatation of the lower half of the pos- 
terior vaginal wall containing a diverticulum of the rectum — a true 
rectocele. 

The various forms are usually combined. The lateral walls are 
rarely affected. In those conditions in which the uterus is nor- 
mally elevated, in conjunction with these affections there may be an 
elongatio colli, extending even to the vulva. Such primary elong- 
ation of the cervix is rare. It results usually through tugging on the 
part of the bladder and vaginal wall. The cervix is then very thin 
and atrophic; this is due either to atrophy after inflammation or to 
atrophy due to the above tugging, and occurs only if the uterus was 
firmly fixed. 

In line with the fact that the etiology of acquired retroversio 
flexio is pelvic subinvolution, it is found that the most frequently 
noted form is cystocele with retrodeviation of the uterus. Next 
in frequency is cystocele, plus rectocele. The latter is due to lacer- 
ation of the perineum and to injury to the perineal and rectal in- 
sertion of the levator ani. Least frequent, supposedly, is cystocele 
alone. My experience, however, shows the last form, existing alone, 
to be much more frequent than generally stated. A prolapse of the 
uterus with invagination of the vagina occurs most frequently after 
the climacterium, as a result of senile atrophy of the pelvic tissues. 
36 



562 MEDICAL GYNECOLOGY 

Treatment. — For mild degrees of cystocele Skene's pessary 
(Fig. 85) may be tried. Sometimes a small Hodge or Smith 
pessary will be of aid. Occasionally a ring or Menge pessary is 
effective in supporting the uterus and lifting up the cystocele. 
Operative relief is the wisest. Even with shortening or fixation of 
the round ligaments or with ventral fixation a cystocele frequently 
recurs after anterior colporrhaphy. Two factors may be stated 
as certain: (1) The correction of a retroflexion by these methods, 
though advisable, is not essential in the correction of a cystocele; 
(2) treatment of the posterior wall of the vagina is not the essential 
factor in correcting the lesion in the anterior wall. Theilhaber 
treated surgically twenty-four patients, almost all of whom showed 
an elongatio colli. The anterior colporrhaphy consisted in making 
the excision extend far, laterally, into healthy tissue. He resected 
the anterior vaginal wall up to the lateral wall, paying little or no 
attention to the posterior vaginal wall or to the perineum. Out of 
the twenty-four patients thus treated, twenty-two remained with- 
out recurrence; the other cases could not be traced. There were 
no recurrences, in spite of the fact that fifteen cases had retroflexed 
uteri which were not treated surgically. 

The good results obtained by Theilhaber were due: (1) to so 
changing the character of the anterior vaginal wall that the upper 
ends of the levator ani muscles were brought close together; (2) 
to narrowing the anterior wall of the vagina; and (3) to removing 
the thin urethrovaginal septum, and so closing the space on the 
under surface of the bladder, through which this organ formerly 
descended. 

Another valuable method, and one which is of considerable im- 
portance, in the vaginosuspension or vaginofixation of the uterus 
according to the method of Duhrssen. Although the value of the 
latter in the case of women past the child-bearing period is generally 
acknowledged, this favorable opinion as to the use of the former 
in younger women with cystocele who are to bear more children is 
not general. Without going into the question further, suffice it to 
say that the experience of my teacher, Duhrssen, since the perfection 
of his method, and my own experience in over one hundred selected 
cases, leave no room for criticism of this method of supporting the 
bladder. It is remarkable how slight are the vesical annoyances 



VAGINAL HERNIAS 563 

associated with cystocele. The patients simply feel a protrusion 
on standing or on straining and usually say "the womb is coming 
down." With rectocele, and its associated injury to the levator 
ani muscles, constipation and inability to force out the feces felt 
in the rectum are the most noticeable complaints. There is a sen- 
sation of pelvic looseness. Senile vaginitis makes these conditions 
annoying. In the operative correction of rectocele it is essential 
to unite the torn rectal ends of the levator ani muscles. 



PREGNANCY AND ABORTION 
Early Diagnosis of Pregnancy.— In the third or fourth months 
of pregnancy the introitus vaginae is so typically dark blue that this 
condition is pathognomonic, but in the very early weeks there is only 
a slight bluish discoloration of the vaginal wall, especially on the ure- 
thral prominence. This is usually most distinct in multiparas. In the 
early weeks of pregnancy the vagina and cervix become succulent 
and there is increased secretion. The cervix, as expected, shows the 
earliest bluish discoloration in early pregnancy, for this tinge of blue 
is frequently present just before menstruation also. The portio 
becomes softer, especially at its lower end . The most important sign 
is enlargement of the uterus, which becomes broader and thicker. 
The uterus in the first three months grows faster than does 
the ovum because it grows in part independently of the ovum. At 
the fourth month, when the cavity of the uterus is obliterated 
by the union of decidua reflexa with decidua vera, the growth of 
the ovum causes growth of the uterus. The uterus grows con- 
tinually softer, so that in the fourth month it is sometimes so soft 
that the fundus is not readily made out, and the error is frequently 
made of mistaking the portio for the uterus. The fundus when 
made out may be mistaken for a cystic tumor. This error is due 
to the fact that the line of division between the firm cervix and the 
extremely soft fundus is so soft that a connection between these 
two parts of the uterus does not seem to exist. In the earlier 
months also this area of softening is marked in the lower uterine 
segment, even if the cervix and fundus feel firm. If the internal 
examining fingers are placed in the anterior fornix, and if the ex- 
ternal hand is passed over the posterior wall of the uterus until the 
tips of the fingers reach the region of the internal os, the tips of the 
external and internal fingers come into contact as if no uterine 
tissue were present. This means that the soft edematous anterior 
and posterior walls of the lower uterine segment are neither of the 
firmness of the cervix nor of the cystic or firm character of the 
fundus. This condition, made out by bimanual examination, is 

564 



PREGNANCY AND ABORTION 



565 



one of the earliest sure signs of uterine pregnancy, and is called 
the sign of Hegar (Fig. 125). 

In the early weeks of pregnancy in uniparae or multiparae a 
differential diagnosis must be made from chronic metritis and from 
fibrosis uteri. In these states the uterus is enlarged and may oc- 
casionally be soft. The cervix may be soft in conjunction with 
fungoid hyperplasia of the endometrium, so that the differential 
diagnosis from pregnancy in the first two months is often difficult. 
There is, however, no blueness of the introitus or of the vagina and 




Fig. 125. — The method of determining that softness of the cervix at the region 
of the internal os known as Hegar' s sign. It often seems to the examining fingers 
as if the cervix and the soft fundus were not connected at all. 



there is no sisrn of He^ar. There is no history of amenorrhea ex- 
cept in nursing women, and in them the uterus is small. A definite 
diagnosis can be made by noting the growth of the uterus after an 
interval of two or four weeks. Asymmetry of the two cornua is 
an important sign, the uterus changing in size and outline during 
examination. 

Embedding of the Ovum. — A fecundated ovum shows upon 
its outer surface a development of cells known as trophoblast cells. 
It is from these trophoblast cells that the covering of the future 



5 66 



MEDICAL GYNECOLOGY 



chorionic villi and the placenta are formed. The characteristic of 
the trophoblast cells is that by enzyme action they burrow their 
way into the decidua, digest the tissues in their periphery, perforate 
the blood-vessels, and thus receive their nutrition from the ma- 
ternal circulation. These cells form the two-layered covering of 
the villi, the syncytium and the cells of Langhans. The uterine 
lining develops into decidua by a great hypertrophy of the con- 
nective-tissue cells, accompanied by dilatation of the vessels and 
congestion of the whole uterus. So delicate is the relation between 
the growing ovum and its trophoblast cells on the one hand, and 
the decidua and the maternal blood on the other, that the wonder 



Membrana chorii 



Syncytium j 



Mesoderm 



Fetal capillaries 




Intervillous space 



Mat. lacuna Fibrin 



Fig. 126. — Diagrammatic representation of the formation of the villi; their struc- 
ture of trophoblast cells, their covering of syncytium, and their delicate connection 
with the decidua, as well as the growth of trophoblast cells into the decidua (after 
Peters). 



is not that abortion takes place, but that it does not take place 
more frequently (Fig. 126). 

Changes in Ovum. — Abnormalities in the ovum itself may be 
the cause of abortion. These abnormalities consist first in a 
syphilitic change. It may be taken for granted, even though this 
cannot be verified in the early cast-off ovum, that an ovum made 
syphilitic by the fecundating spermatozoon produces an abnormal 
character of cells, and the viability of the little embryo is readily 
involved. If then, at a very early stage, there is death of the 
embryo, or if the cells from which the chorionic villi and the future 
placenta are formed are not healthy ones, it can be seen that the 
relation between ovum and decidua may be readily disturbed. 
The ovum is then a foreign body, uterine contractions take place, 



PREGNANCY AND ABORTION 567 

and abortion results. If in the early course of pregnancy, through 
any form of maldevelopment or through any form of involvement 
of the cord the embryo dies, abortion results. Any disease of the 
mother which results in an exchange of toxic products may injure 
the ovum, cause the death of the embryo, and force its expulsion. 

Changes in Maternal Tissues. — The greater number of abor- 
tions, however, result from involvements of the maternal tissues. 
Here syphilis of the mother may be an influence, in that the pro- 
cesses of placental development are carried on in abnormal de- 
cidual tissues. There may be, in addition, a failure of proper nu- 
trition of the ovum. Diseases associated with high temperature 
may destroy the embryo. If the mother is suffering from an in- 
fectious or other disease which produces toxins that poison the 
embryo or which alter the character of the endometrium, we are 
concerned then with a cause of abortion. Endometritis implies 
an involvement of the uterine lining, inflammatory or non-inflam- 
matory. It can be readily seen that an inflammatory involvement 
resulting in great congestion of the uterine mucosa, or resulting 
in atrophy of the uterine mucosa, with or without a change in the 
vessels, destroys the delicate balance between ovum and decidua 
or fails to give opportunity for sufficient nutrition of the fetal cells. 
Overgrown uterine mucosa in the form of hyperplasia, accompanied 
as it is with tendency to hemorrhage at menstruation and associated 
with dilated capillaries and vessels, causes ready capillary hemor- 
rhage. The growth of the trophoblast cells and the extension of 
the chorionic villi is supposed in every case to perforate capillaries ; 
but if these capillaries are sclerotic or diseased ones, or if congestion 
is marked, too much blood is forced out and the ovum is loosened 
from its contact with the decidua serotina or perforates the decidua 
reflexa. This is perhaps the most frequent cause of abortion, es- 
pecially of repeated abortions. An ovum which settles in the lower 
segment of the uterus and which develops there will result eventually 
in the production of a placenta praevia. It is quite probable that 
many cases of abortion, especially in the early weeks, are instances of 
ova situated in the lower segment of the uterus, the part which is 
not intended for early stretching and growth, and for that reason 
uterine contractions take place to an unusual degree and the ovum 
is thrown out. It is probable that placenta praevia indicates the 



568 MEDICAL GYNECOLOGY 

existence of an abnormal endometrium, an endometrium which 
does not permit of the location of the ovum near the fundus, and 
for that reason results in its descent to the region of the internal os. 

Changes in the Uterine Wall.— Changes in the uterine wall 
may be responsible for abortion. A uterus which is inflamed by 
metritic processes, which is hypertrophied as the result of sub- 
involution, accompanied as it is by congestion and arterioscle- 
rosis, is either stimulated to undue contractions in the course of 
pregnancy or else is liable to bleeding from brittle arteries. Every 
uterus, whether pregnant or not, undergoes normal painless con- 
tractions, which is nature's method of keeping the uterine muscle 
in good condition. These painless contractions continue, and in 
the later months of pregnancy are known as the Braxton-Hicks 
painless contractions. An inflamed or sensitive uterus reacts by 
unusual contraction to the presence of the growing ovum, and if of 
sufficiently marked character, the result is hemorrhage and me- 
chanical loosening of the ovum. We must consider hypoplasia of 
the uterus too a cause of abortion, especially in first pregnancies. 
The uterus is then somewhat small, the decidua does not develop a 
sufficiently rich character, the uterine wall is thin, the necessary 
hypertrophy and hyperplasia of the uterine wall do not occur, the 
uterus does not grow sufficiently, and abortion in the early months 
may take place. 

There are abnormalities in the ovum which may result in abor- 
tion, either through their action on the uterine wall or because they 
result in the death of the embryo. We refer here particularly to 
the change known as hydatid mole. It is more than probable that 
many cases of abortion, especially those in which the ovum is 
thrown out as a whole, are microscopic early forms of hydatid 
mole, which only microscopic examination can verify. 

There are other conditions within the uterus of a rather unusual 
nature which are likewise the cause of abortion. A septate uterus 
is such a cause. An ovum here develops in only one-half of the 
uterus, its growth is limited by the septum, changes in blood-supply 
result, and abortion may take place. 

Uterine polyps, and particularly unrecognized submucous fib- 
roids, are productive of abortion. They produce bleeding or hem- 
orrhage in the uterine mucosa or mechanically prevent the growth 



PREGNANCY AND ABORTION 569 

of the ovum and bring about uterine contractions which expel the 
growing ovum. 

Displacement of the Uterus. — Displacements of the uterus, 
especially retroflexion, are considered to be a cause of abortion 
through the abnormal congestion which they produce and the 
consequent tendency to minute or greater bleeding. While this 
is true in some cases, yet pregnancy to full term in retroflexions is 
an almost every-day occurrence, while in other cases the correction 
of the displacement by pessary or operation fails to prevent sub- 
sequent abortion. Isolated single abortions are so frequent and 
occur for so many different reasons that the non- recurrence of this 
condition after the correction of retrodeviations should not be 
considered too great a proof of the importance generally attached 
to uterine displacements, as endometritis and metritis and fibrosis 
may be the important factors. Of course, a retroflexion should be 
corrected to prevent an incarceration of the uterus when pregnant, 
in the true pelvis, and to avoid the future risk of prolapse of the 
uterus. Physical injury and physical shock, etc., may produce 
abortion by mechanical action if they result in unusual hemorrhage 
from the vessels about the ovum or produce a mechanical separation 
of some of the chorionic villi. Blood accumulates between the 
ovum and the uterine wall and the ovum is cast off. Abortion pro- 
duced by drugs or intrauterine manipulation is not considered 
here. 

Symptoms. — The symptoms of abortion are bleeding, pain 
caused by uterine contractions and by dilatation of the cervix, 
and local evidences of an attempt at expulsion of the uterine 
contents. The bleeding is either the primary or the secondary 
factor. It is primary if a hemorrhage takes place which acts as a 
mechanical factor in separating the ovum. It is secondary if 
the ovum dies or is partly separated, and, being then a foreign 
body, the uterus contracts in its attempts to expel it. Uterine con- 
tractions continue to separate the ovum, more bleeding takes place 
between ovum and decidua serotina, and blood is poured out of 
the cervix. The pain associated with abortion is due to uterine 
contractions and to cervical dilatation, and for exactly the same 
reasons as at full term. The uterus contracts close down upon the 
egg, blood accumulates in the uterus, the uterus contracts to expel 



570 MEDICAL GYNECOLOGY 

the blood, and this process continues until the broken or unrup- 
tured ovum is entirely loosened from contact with the uterine wall. 
It is not alone the uterine contractions, but also the dilatation of the 
cervix which produce the pain. The degree of dilatation of the 
cervix, then, is one of the means of determining whether abortion is 
progressing or not. Given a uterus which is bleeding, in which 
pain is slight, in which the cervix is not dilated, and we are here 
concerned with a case in which the bleeding and the progress of the 
abortion may under proper treatment cease. If, however, bleed- 
ing continues, it threatens the life of the ovum. If the blood is 
poured out rapidly and accumulates in the uterus in the form of 
clots, it stimulates the uterus to further contractions. If the ovum 
is partially separated from the uterine wall, or if the embryo is 
dead, the uterus naturally reacts by further contractions. There- 
fore the continuation of uterine pain and the increasing dilatation 
of the cervix are indices of an inevitable abortion. 

In the bleedings which occur during pregnancy, involvement of 
the vagina, portio, and cervix can be excluded by examination. 
Regular bleeding may come from a double uterus. Bleeding from 
a pregnant uterus may occur as the result of an existing fungoid 
endometrium. There may be a long-continued oozing, especially 
of brownish blood mixed with mucus. There are recurring pains, 
but not of marked severity and not accompanied by the loss of much 
blood or by dilatation of the cervix. The bleeding comes from 
the lining of the uterus, from the decidua vera. An endometritis 
deciduae (inflammatory) is a frequent cause of habitual early abor- 
tion. Ectopic gestation must always be considered and differentiated. 

An inevitable abortion is associated with the loss of much blood 
and of fresh blood, whereas irregular bleeding or the loss of brown- 
ish blood mixed with mucus does not indicate immediate danger. 
When, in addition to the loss of fresh blood, pains come on, this 
combination has a more direct meaning. If at the same time the 
uterus becomes more tense or becomes harder, it indicates that 
abortion is in progress. If, then, the cervix is open and the in- 
ternal os admits one finger, we are concerned with dilatation of 
the cervix, which is a most important sign of inevitable abortion. 

Hegar's sign is important in early cases seen for the first time 
in whom pregnancy has not been previously diagnosed, especially 



PREGNANCY AND ABORTION 571 

so if there is a history of long- continued irregular menstrual periods 
and for the purpose of excluding ectopic gestation. An important 
aid is the introduction of the finger into the uterus when the cervix 
is open. In beginning abortion the finger feels the round ovum 
more or less cystic. In incomplete abortion the finger feels re- 
tained sac or decidua or retained placenta, which are recognized 
by the fact that they can be peeled off with the fingers. Sometimes 
such structures are seen projecting from the cervix. 

Treatment. — The treatment of inevitable abortion consists in 
producing the steps involved in normal labor. In labor dilatation 
of the cervix is aided by uterine contractions which force the "bag 
of waters" into the cervix and by the upward pull of the cervical 
fibers around the presenting part of the child, as if pulled around a 
pulley. Continued uterine pains expel the contents, and further 
contractions of the uterus in the third stage loosen the placenta and 
expel it. Therefore the treatment of abortion consists in aiding 
dilatation of the cervix, in aiding the separation of the ovum and 
placenta, and in aiding the expulsion of the contents. At the same 
time the interests of the patient should be conserved by limiting 
the hemorrhage as much as possible. The very means which are 
best adapted to preventing an excessive loss of blood happen to be 
the very means which are of the greatest value in dilating the cer- 
vix. If an abortion is inevitable and if it is desired to carry out 
the procedure in the simplest manner, the following should be 
done with strictest surgical aseptic precautions. The vulva, the 
vagina, and the cervix should be thoroughly cleansed. With the 
aid of a bivalve speculum or with the aid of Sims specula the 
cervix should be grasped by volsellum forceps, and a long strip of 
iodoform gauze, its width depending on the dilatation of the cervix, 
should be introduced into the cervix and as much passed up into 
the uterus as possible. The cervix should then be packed as 
thoroughly as possible. The vagina, from the fornices to the in- 
troitus, should be packed with a very wide strip of iodoform gauze 
arranged in plaited form, thus furnishing a packing which com- 
pletely and solidly fills the vaginal canal. With the aid of a T- 
bandage and gauze about the vulva the vaginal packing should be 
kept in place. Ergot, dram j, or ergotol, dram J, should be admin- 
istered every two or three hours. The vaginal packing prevents 



572 MEDICAL GYNECOLOGY 

the exit of blood from the uterus and hemorrhage is diminished to 
a minimum. Through the gauze within the cervix, dilatation of 
the cervix is produced. As a result of the packing in the vagina 
and the cervix the blood thus poured out in the uterus is retained 
within it. Contraction of the uterus compresses this blood, the 
poured-out blood dilates the uterus and cervix, accumulates be- 
tween the ovum and the uterine wall, and is an important factor 
in peeling the ovum away from its contact with the uterine wall. 
Contraction of the uterus and the effort of the uterus to expel the 
ovum and clotted blood dilate the cervix. If this packing is re- 
moved at the end of twenty-four hours, the cervix will be found 
considerably dilated . The same steps as mentioned above should be 
repeated, if necessary, but a wider piece of gauze should be packed 
into the uterus and especially into the cervix. The vagina is then 
thoroughly packed and the use of the ergot is continued. It rarely 
takes more than forty-eight hours with this method to dilate the cer- 
vix so that it readily admits the middle finger (Fig. 70). At the same 
time the ovum and the chorionic villi or placenta are often com- 
pletely loosened from the uterine wall. The cessation of uterine 
pains can generally be taken as proof of separation of the ovum. 
At the end of the forty-eight hours, then, the gauze is removed, and 
not infrequently the ovum is so situated that placental forceps in- 
troduced into the cervix can grasp it and remove it — sometimes 
the fetal sac with the embryo, at other times the fetal sac and then 
the embryo. 

If the placental forceps do not grasp the loosened contents, chloro- 
form is generally necessary, and the middle finger, under the strict- 
est aseptic precautions, is introduced into the cervix and uterus; 
the other hand, pressing through the abdominal wall, pushes the 
uterus down into the pelvis and presses on the fundus (Fig. 70). 
In this way the middle finger of the internal hand can palpate the 
entire uterine cavity, can separate the whole ovum or the adherent 
parts or remove whatever of fetal sac or placenta is attached. After 
this procedure the placental forceps carefully introduced can ex- 
tract whatever loosened contents are in the uterus. The uterus 
should then receive a very hot douche, with a double-running 
irrigator, of 1 per cent, lysol (Fig. 65). If the finger has been 
unable to separate any of the placental tissues, their location at 



PREGNANCY AND ABORTION 573 

least is noted, and placental forceps or a large blunt arret are then 
introduced for their removal. The uterus is then packed with 
iodoform gauze and ergot is administered. The vagina is also 
packed with iodoform gauze. The gauze is removed in from twenty- 
four to forty-eight hours and ergotol, 15 minims, is administered 
every four hours. In incomplete abortion it is rarely necessary 
to use the sharp curet unless, in very early cases, the uterus is so 
small that the finger method cannot be used (Figs. 65, 66, 67). 
The use of the sharp curet is a dangerous thing. First, we are 
never sure that we have removed all the products of conception; 
second, perforation of the uterus occurs very readily. During 
the manipulation of the curet the uterus dilates and contracts easily, 
as it does in the post-partum period at full term, and if the curet is 
held very firmly, simple contraction of the uterus is enough to cause 
perforation by this sharp instrument. 

It is by no means infrequent to find in abortions at the tenth or 
twelfth week, when an embryo is spontaneously expelled, that 
decidua, the sac of the ovum, or placental remnants are retained. 
These, as a rule, prevent the uterus from returning to normal size, 
the cervix does not contract, and there is generally a steady or ir- 
regular loss of blood. Under these circumstances the same method 
of dilatation of the cervix by iodoform gauze and of examination and 
cleansing of the cavity with the finger is most advisable. If this pro- 
cedure is not possible, the dull curet should be used with the greatest 
of precaution (Figs. 65, 66, 67, 69). In using the curet in the uterus, 
it is essential to first measure the length of the uterine cavity with a 
sound, and then to place the index-finger of the right hand on the 
curet at a point which makes the distance from the tip of the curet to 
the finger a little less than the length of the uterine canal, as measured 
by the sound (Fig. 66). Curettage is then done, with the finger 
held firmly on this point, so that the instrument at no time enters 
further into the uterus than the measured length. The above des- 
cribed method of painless, slow dilatation of the cervix by the use 
of iodoform gauze is a safe and certain procedure. The above 
method of removing the contents of the uterus by the introduced 
finger is certainly the safest. The finger recognizes adherent 
tissues ; it locates any tissue that cannot be scraped off ; it cannot 
perforate the uterus. It makes diagnosis and carries out the treat- 



574 MEDICAL GYNECOLOGY 

ment. It should be used in every case in which the uterus is three 
times the normal size. Otherwise, instead of curage, curettage 
must be done (Figs. 65, 66, 67). 

The diagnosis of incomplete is difficult when the cervix is closed. 
The continuation of pain speaks for the retention of the clots or of 
large masses, and bleeding continues. The uterus may be enlarged 
through the thickness of its own walls rather than through the 
size of its contents. The sound may show irregularities or rough- 
ness, but its use causes ready bleeding. Winter says that the larger 
and softer the uterus, the more does it speak for the retention of 
fetal and decidual products. 

The death and retention of the embryo and ovum in the first 
months of pregnancy result in a diminution of the succulence and 
blueness of the vagina and cervix. The uterus becomes harder. 
Bleeding is less frequent than in abortion. The important aid in 
diagnosis is observation of the fact that the uterus does not in- 
crease in size in the course of several weeks, or that the uterus is 
much smaller than the length of the amenorrhea warrants. The 
chorionic villi may grow after the death of the embryo. Such an 
ovum is found to be covered by thickened decidua. Decidua 
serotina especially is thickened and infiltrated with blood. There 
is little amniotic fluid and the embryo may be present or degen- 
erated. Such an ovum has been called bloody mole if fresh blood 
is present, and fleshy mole if decolorized old blood is present. 

In some cases the entire placenta may be retained within the 
uterus. Bimanual examination shows a large uterus, often a dilated 
cervix, and the diagnosis generally made is submucous fibroid or 
chorioepithelioma. In fact, with very adherent placenta exam- 
ination by the finger does not always make the differentiation. 
Such a placenta may be retained in the uterus a year or more, and 
if it undergoes no putrefactive changes the diagnosis is indeed 
difficult. More frequent is the retention of a decidua which does 
not undergo involution, but remains as a hypertrophied hyper- 
plastic lining, giving rise to menorrhagia and repeated abortions. 

Most frequent is retention of microscopic fetal cells in the form 
of villi or the cells which cover the villi, the cells of Langhans, and 
the syncytium. The most frequent causes of repeated abortion 
are syphilis, retroflexion, endometritis, fungoid endometrium, me- 
tritis and fibrosis uteri. 



PREGNANCY AND ABORTION 575 

Abortion is most frequent in the third month, when the chorionic 
villi begin to atrophy, except at the serotina, the future placental 
site. The danger periods in repeated abortions are the omitted 
menstrual days, i. e., the periods when menstruation would have 
occurred had no pregnancy taken place. 

In bleeding occurring in the early months, when abortion is 
perhaps avoidable, the treatment consists of rest in bed, fluid diet, 
morphin by the needle or opium by suppository, and 2 grains of 
stypticin taken every two or three hours. Rest in bed is essential. 
For habitual abortion virburnum prunifolium should be given es- 
pecially at the weeks corresponding to the omitted menstrual 
periods, and those weeks should be spent in bed. Standing, lift- 
ing, and work should be avoided. It is wise to let a long period 
of rest with treatment of uterine conditions precede the next preg- 
nancy if the patient comes for consultation in the non-pregnant 
state. A syphilitic cure is advisable if examination or history 
points to this etiology. The husband must be sent to a specialist 
for treatment. 

Infections result from bacteria present in the uterus (gonococcus) 
or introduced in attempts at artificial abortion, or introduced 
through lack of most thorough aseptic precautions during exam- 
ination or treatment. Putrefactive bacteria growing on retained 
products cause a sapremic endometritis with disagreeable odor. 
Streptococci, staphylococci, gonococci, etc., invade either the en- 
dometrium or the uterine wall, or extend out into the parame- 
trium, the tubes, the peritoneum, or produce a thrombophlebitis 
or a general septicemia. The treatment is found under Endome- 
tritis, Parametritis, Metritis, Salpingitis, Pelveo-peritonitis. 



MYOMETRIAL DEGENERATION, FIBROSIS, AND 
ARTERIOSCLEROSIS 

Causes of Uterine Hemorrhage. — In gynecologic hemorrhages, 
if those from the vulva, vagina, and portio vaginalis be excluded, 
visible bleedings are limited to the cervix and the uterus. Acute 
infections cause a certain amount of hemorrhage, but large losses 
of blood from the cervix are due either to carcinoma, sarcoma, 
myoma, or polyps, conditions easily diagnosed on proper examina- 
tion. The intact lining of the cervix does not bleed, taking no 
part in menstruation. An affected lining of the cervix bleeds less 
frequently than the lining of the corpus uteri, for it takes but 
slight part in the physiologic swelling of menstruation. 

Bleeding from the corpus uteri may be due to local conditions, 
to affections of the adnexa, to general physical disturbances, to 
nervous or temporary circulatory phenomena. The only normal 
uterine bleeding is menstruation. Every very strong menstrua- 
tion or every irregular bleeding must be viewed as pathologic. 
If the uterus on examination be found enlarged, the following 
conditions must be looked for: myoma or sarcoma of the uterine 
wall; carcinoma, sarcoma, or large polyp of the endometrium; 
chronic metritis with endometritis ; the complications of pregnancy, 
such as endometritis, placenta prsevia, abortion, retention of placenta 
or decidua, chorioepithelioma, subinvolution, ectopic gestation. 
If the uterus be not enlarged, there may be present endometritis 
or a malignant change, or a degeneration of the myometrium or 
ectopic gestation. If on examination with a sound the inner lining 
feels smooth and even, the endometrium is probably normal. Of 
the secondary hemorrhages from the uterus, a not infrequent cause 
is acute pyosalpinx. In this category, above all, extrauterine ges- 
tation must be taken into consideration. Bleedings due to tumors 
of the ovary are rare, and if they do occur are the result of bilateral 
tumors, especially carcinomata. The peritoneal causes of uterine 
bleedings come under the head of pelveo-peritonitis ; in that case 
the associated endometritis and periuterine exudate are the probable 

57 6 



MYOMETRIAL DEGENERATION; FIBROSIS; ARTERIOSCLEROSIS 577 

causes. This holds true likewise of the bleedings complicating 
parametritis. 

Climacteric Bleedings. — Among the other forms of decided 
uterine hemorrhage, the most important are the so-called bleed- 
ings of menopause. At the climacterium a gradual disappearance 
of menstruation, becoming less and less at each period, is rare. 
Without a previous diminution in the amount of blood lost periodi- 
cally the menses, as a rule, are absent for one or two periods; they 
then return at the regular time, usually increased. The interval 
between the individual bleedings is rarely more than five or six 
months. The loss of blood, as a rule, does not reach a dangerous 
height, but these bleedings may occur often and last long. We 
may have at first a too early appearance of increased menstruation, 
and then later a delayed appearance of increased menstruation. 
In other cases there is a constant oozing of blood until the next 
flow appears. Even after a disappearance of menstruation for 
half a year or a year, a bleeding may again occur, so that it is 
difficult to say when a final cessation has taken place. In such 
cases endometritis, myoma, and carcinoma must be excluded, for 
if after an absence of six or more months a bleeding occurs, it 
should be considered pathologic until proved otherwise. Not 
infrequently there occur at the natural climacteric age, and like- 
wise much earlier, the so-called climacterium praecox, most decided 
and long-continued bleedings, for which no apparent cause can be 
found. 

We have at the menopause age, and also much earlier, hemor- 
rhages without decided changes in the endometrium, and without 
the presence of new-growths. The bleedings are frequently 
stopped with difficulty and recur. These often continue in 
spite of rest in bed and the use of stypticin, hydrastin, ergotol. 
Even curetting and atmocausis have no effect, and not so very 
rarely hysterectomy is necessary. 

Why do these profuse bleedings occur, and why is this condition 
found in younger women? What is the cause, what is the treat- 
ment? 

This form of decided hemorrhage is due to fibrosis uteri, to 
degeneration of the myometrium, or to local uterine atrophic 
changes caused by a cessation of trophic function on the part of 
37 



57§ MEDICAL GYNECOLOGY 

the ovary and its secretion. Even though the only symptom is 
profuse hemorrhage, since the same changes are found in the 
uterus in unexplainable bleedings in younger women, we must 
view many of these latter cases as due to the same causes. Among 
the pathologic changes which are responsible for these bleedings, 
in addition to fibrosis uteri and myometrial degeneration is uterine 
arteriosclerosis. 

Trophic Changes in the Uterine Muscle. — Halban found that 
castrated newly born guinea-pigs showed no future development 
of the genitalia, and no development of the uterine muscle. 
Knauer found, after castrating rabbits, that the uterus atrophied 
and that the intermuscular connective tissue was increased. Soko- 
loff castrated dogs and found that the uterus, especially the circular 
layer, became atrophied, the vessels were thickened, and their 
lumen became smaller. Jentzer and Beuttner, on castrating cows, 
found an atrophy of the muscle and of the glands of the uterus, 
and increased growth of the connective tissue and changes in 
the stratum vasculare. 

After castration the uterus atrophies. Benkisser found that the 
vessels of a uterus, removed three months after castration, showed a 
sclerosis and an endarteritis obliterans. Eckhardt found, one year 
after castration, that the uterus of a woman was atrophied, the en- 
dometrium likewise, and that the connective tissue was increased. 
Gottschalk found, one and one-half years after castration, that, 
although the muscle of the uterus was well retained, the mucosa was 
atrophied and that the large vessels showed a folding of the intima. 
Therefore, after castration, the changes are like those occurring at 
the menopause. At and after menopause the uterus undergoes re- 
gressive changes, the portio shrinks, and we have the so-called 
senile uterus. The wall is thin and dry and contains much con- 
nective tissue; the vessels are thickened, narrow, and calcified. 
The mucous membrane is thin, flattened, and indurated. 

This change occurs likewise in younger women, and is due to 
an early diminution of trophic and nutritional function on the part 
of the ovary, or to uterine atony dependent on constitutional causes. 
Why this early change in the ovaries should occur in certain cases 
we do not know, for in our discussion we exclude those conditions 
resulting from acute infectious diseases or periuterine inflammation. 



MYOMETRIAL DEGENERATION; FIBROSIS; ARTERIOSCLEROSIS 579 

Such atonic changes in the uterine muscle at climacterium, and 
increased changes of this kind in earlier periods, explain in part 
the irregular and profuse hemorrhages in some patients and the un- 
controllable hemorrhages in others. 

Elastic Fibers of the Uterus. — The elastic fibers of the 
uterus run between the muscle bundles, upon the surface of the 
bundles, they may surround a fasciculus or they may perforate it. 
In the stratum vasculare, where the elastic fibers come from the 
adventitia, finer fibers are found in the interfascicular connective 
tissue, but most of these are not connected with the main fibers. 
They are sometimes absent in the virgin uterus. Elastic and 
fibrous tissue, situated between the muscle bundles, sends branches 
between and around every muscle cell, but always at right angles 
to the long axis of the cell. The individual muscle cells of the 
stratum subserosum have therefore a perimysium elasticum and 
a perimysium fibrosum; the muscle cells of the stratum supra- 
vasculare and the stratum vasculare have a perimysium "fibrosum 
and often a perimysium elasticum. The fibers of the stratum sub- 
mucosum have only a perimysium fibrosum. 

The important muscle fasciculi are furnished with a framework 
or elastic support which protects the fibers from overstretching 
and permits their return to normal position on contraction. This 
elastic framework is especially well developed in the outer layer 
and permits any change of form on the part of the fibers. This 
arrangement whereby the main amount of elastic tissue is placed in 
the outer two layers of the uterus has the advantage that it does not 
interfere with the contraction of the vessels; besides, any two 
points in the periphery are further separated, on dilatation of the 
uterus, than two points nearer the center, so that this supply is 
adapted to subsequent demands. The arrangement whereby the 
elastic fibers are arranged at right angles to the muscle fibers prevents 
any interference with contraction of the muscle and the vessels. 
The above-mentioned is the natural condition found between 
birth and the climacterium, namely, elastic fibers in the inter- 
stices of the muscle bundles and the muscle fibers (Pick). 

Changes in the Elastic Fibers. — In the first half of pregnancy, 
so long as the myometrium grows, the elastic fibers undergo hyper- 
plasia. The same is true of the parauterine and periuterine elastic 



580 MEDICAL GYNECOLOGY 

fibers. In the second half there is diminution, probably relative, 
through stretching; possibly, however, there is an absolute diminu- 
tion. This seems to be irrational, in view of the future stretching 
to which the lower uterine segment is to be subjected during labor; 
but in pregnancy there is a huge increase in the elastic structures 
situated at the sides o| the uterus and around the lower uterine 
segment, so that on subsequent dilatation there is no interference 
with the muscle fibers of the uterine wall. This vicarious growth 
of powerful parametrial and perimetrial elastic fibers, the course of 
the uterine fibers at right angles to ,the line of contraction of the 
muscle bundles, the network of elastic and fibrous perimysium 
about the individual fibers, the equal distribution and course of 
the fine elastic fibers in the external wall of the uterus, are ideal 
conditions ; yet this typical arrangement is somewhat lost in preg- 
nancy, and the vessels of the stratum vasculare show proliferation, 
and so do the elastic fibers of the intima. 

During the puerperium, however, there is a decidedly increased 
formation of elastic fibers, and after labor their increase is per- 
manent, hand in hand with a hypertrophy of the muscle fibers 
and a thickening of the vessels. 

The typical arrangement of the elastic fibers is lost in pregnancy, 
at the climacterium, and likewise on the presence of myomata and 
in chronic metritis. The fibers are thickened and increased 
in number, and we might say that the typical arrangement is height- 
ened in chronic inflammations, in the first half of pregnancy, and 
at the puerperium. The fibers are swollen through serous infil- 
tration in pregnancy, in the puerperium, and in metritis exudativa. 
The fibers are degenerated in pus infiltrations. The fibers increase 
in thickness up to the age of fifty. After fifty they lose their con- 
tinuity and become brittle and irregular. In old age they form 
lumpy groups in which the individual elastic fibers are to be 
scarcely recognized, and form groups around the arteriosclerotic 
vessels which are likewise grouped together. The elastic fibers dis- 
appear from the interfascicular connective-tissue interstices so that 
the circumvascular islands of elastic fibers lose all connection with 
each other. 

In the senile uterus the elastic fibers of the corpus and cervix 
are increased. A like condition is found in castration atrophy, 



MYOMETRIAL DEGENERATION; FIBROSIS; ARTERIOSCLEROSIS 581 

and in addition the walls of the vessels are thickened and the 
elastic fibers in the adventitia are increased in amount. In 
older uteri there is then an increased supply of elastic fibers. 
This is not alone a local condition, but is part of a general 
increase, such as takes place in the kidney, liver, heart, spleen, 
etc., and is an attempt at compensation for the disturbed mechan- 
ical relations due to the loss of epithelial and muscular tissue. 
It is true then that the greater the atrophy, the larger is the num- 
ber of elastic elements, and that an increase of elastic elements is 
present in all atrophies of the uterus, whether natural, artificial, or 
as a result of disease. The elastic fibers in the arteriosclerotic 
vessel walls of the stratum vasculare are increased and, passing 
out into the myometrium, they take the place of the muscle bun- 
dles, which is of itself a proof that the adventitia is a source for 
their formation. 

We have, therefore, a hyperplasia of the connective tissue 
hand in hand with a gradual degeneration of the muscle fibers 
at climacterium and in climacterium praecox, so that a frame- 
work is formed in the uterine wall, in the meshes of which lie the 
degenerating muscle cells, accompanied by an increase of the 
fibrous perimysium, especially in the external layers. The elastic 
elements are thickened and lumped, likewise in the pericellular 
and interfascicular spaces. The stratum submucosum has natur- 
ally few elastic fibers, and we have here a lack of elasticity of the 
blood-vessels. Therefore, among the uterine alterations, we have a 
diminution of the muscle-elements, an increased amount of fibrous 
connective tissue, an increased amount of elastic connective tissue, 
an increased amount of elastic elements of poor quality. Even 
if the latter are not increased in amount they are thickened, brittle, 
and form polyp-like groups. The greater the hyaline and sclerotic 
changes in the vessel- walls, the greater is the amount of the elastic 
elements. 

Arteriosclerosis. — Pichevin and Petit curetted a forty-one- 
year-old multipara for continued uterine bleedings, with no im- 
provement. While performing a second curettage the bleeding 
from the uterus was so profuse that it was necessary to extirpate 
it. Examination showed an increase in the number of vessels, 
which showed very much thickened walls, especially in the middle 



582 MEDICAL GYNECOLOGY 

layer of the uterus. The muscular is was found almost substituted 
by vessels. 

Marches! reported a case of a thirty-two-year-old multipara who 
had aborted several times. For great bleedings abrasio was done, 
but the bleedings increased and a hysterectomy was performed. 
The uterus was found to be increased in size and its walls were 
filled with the gaping lumina of blood and lymph- vessels. To- 
ward the mucosa the blood-vessels were increased, so that at this 
part the uterine structure had the appearance of cavernous tissue. 
The adventitia of the arteries showed an increase of connective 
tissue, the intima was thickened and uneven. Marchesi observed 
the occurrence of bleedings which were not controlled by abrasio, 
and where the endometrium showed no great changes. The path- 
ologic condition is therefore a change in the vessels themselves. 
He quoted from the French literature six recent cases of this char- 
acter showing no affection of the glands, of the interstitial tissue, 
or of the uterine parenchyma, but decided changes in the vessels of 
the mucous membrane and the muscular is. 

Reinicke reported four cases, two of which suffered from uterine 
bleedings, which could not be controlled; the other two, in addition, 
showed, on examination of the scrapings, suspicious areas. In 
these cases ergot and ergotin were of no value, dilatation of the 
cervix and the application of liquor ferri brought only temporary 
relief, and extirpation was necessary. Examination showed that 
with degeneration of the muscularis, the arteries had become stiff tubes. 
All four cases showed a thickened media of the vessels and a growth 
of perivascular and intermuscular connective tissue. This con- 
dition is viewed as an arteriosclerosis. 

CholmogorofT reports two cases where the severity of the bleed- 
ings endangered life. No new growths or decided changes of the 
endometrium were present, and curetting brought no relief. The 
first case, a forty- two- year- old Xl-para, had aborted six times. 
Her menstruation had become gradually stronger, returning every 
three weeks, and lasting for eight days, with a loss of much blood 
and many coagula. In the intervals fluor albus was present. 
Hydrastis and ergotin being of no avail, an abrasio was performed 
and showed no abnormal condition of the endometrium. After a 
bleeding which nothing could control, the uterus was extirpated. 



MYOMETRIAL DEGENERATION; FIBROSIS; ARTERIOSCLEROSIS 583 

On section, the vessels of the wall gaped. The mucosa was normal, 
the small vessels showed the intima to be thickened in spo^s, and 
almost obliterated. The muscularis showed an increase in the 
number of vessels, but this was possibly an illusion due to their 
twisted course. All the vessel walls were thickened with a diminu- 
tion oj the lumen. The connective tissue was increased. 

The second case was a patient, twenty-one years old, who had 
aborted twice. Her menstruation lasted eight to ten days, and 
was very profuse, recurring every three and later every two weeks. 
Leukorrhea was also present. An abrasio showed a normal mu- 
cous membrane with hemorrhagic areas. The bleedings recurred 
so often and were so profuse that a hysterectomy was performed. 
The muscularis was firm and grated on incision. The vessels 
looked like pale strips on the cut surface and their lumina gaped. 
The connective tissue was increased. There was a thickening oj 
the arterial walls in the muscularis, especially of the media and the 
intima. There was an increase in the connective tissue, especially 
that seeming to come from the adventitia of the vessels. 



DIAGNOSIS OF MYOMETRIAL DEGENERATION, FIBROSIS, AND 
ARTERIOSCLEROSIS 

We have, therefore, a very clear picture of the pathologic changes 
and of several distinct factors which make a diagnosis positive. 
When menstruation becomes severe, menorrhagia or metrorrhagia 
occurs, and no local changes in the endometrium can be observed 
with a sound or with the examining finger or in microscopic sections, 
we may take it for granted that one or all of the following conditions 
are present: (i) Degenerating muscle fibers poor in contractile 
power; (2) an increased amount of fibrous connective tissue; (3) 
an increased amount of elastic fibers, thickened and brittle; (4) 
arteriosclerotic vessels. Age is no criterion, since these changes 
may occur long before the natural climacteric period. If ergot, 
stypticin, etc., are of no avail; if no decided changes in the adnexa, 
sufficient to warrant their being considered the cause of the hemor- 
rhage be present, if curettings show no altered condition of the 
endometrium; and if, above all, curetting does not control the 
hemorrhage, then the diagnosis of muscular degeneration, fibrosis 



584 MEDICAL GYNECOLOGY 

uteri, or arteriosclerosis must be made. It is scarcely necessary 
to mention that myomata, sarcomata, carcinomata, and other 
local conditions are to be excluded on examination. In these 
cases of fibrotic uterus we usually are dealing with well built, strong 
women who bear even profuse bleedings well. Their ovaries are 
functionating too well and are producing congestions which the 
fibrotic uterus cannot control by proper contraction of the muscle, 
elastic fibers and vessels. 

TREATMENT 

What is the best method of treatment in these cases ? 

For the treatment of these bleedings see sections on Uterine 
Bleedings and on Atmocausis. 

Aside from drugs, uterine and pelvic anemia must be produced 
by appropriate douches, sitz-baths, applications to the lower verte- 
brae, abdominal applications, by the intrauterine application of the 
positive electrode, by intra vaginal pressure-therapy, and by cardiac 
tonics. A curetting, even though in these cases little endometrium 
is present, followed by iodoform packing of the uterus and the ad- 
ministration for weeks of fifteen drops of ergotol several times a 
day, will diminish the size of a fibrotic uterus. Atmocausis, too, 
has a like effect. Soft, thin-walled, atonic uteri are not to be 
curetted. 

If these therapeutic and mechanical methods do not stop the 
bleedings, vaginal hysterectomy must be done. This operation 
is one which I have been led to adopt in many cases, not so much 
because internal medication, sitz-baths, etc., for the production of 
pelvic anemia, curetting, and atmocausis have failed to diminish 
or correct the bleedings, but because patients, when assured of the 
slight risk of the operation, preferred to be freed of their annoyance 
at once rather than lead a quiet life without exertion and with long 
periods of rest, especially during the long menstrual periods. Be- 
sides, assurance that the above measures will avail cannot be given 
with certainty. The rest in bed after hysterectomy lasts no longer 
(not even so long) than the rest essential in these cases after curet- 
ting and atmocausis. 



CARCINOMA 

CARCINOMA VULVAE 

Psoriasis Vulvae, or Leukoplakia. — There are circumscribed, 
white, slightly elevated areas on the inner surface of the large and 
small labia. Carcinoma often develops from these as it develops 
from like lesions on the tongue. So soon as the surface becomes 
papillary and infiltration occurs around the base, it is probably 
carcinoma. Carcinoma may also develop from the vulvar condi- 
tion known as vulvitis pruriginosa. 

Carcinoma of the vulva may begin in the glands situated around 
the external meatus of the urethra, in the prepuce or small labia. 
It is most frequent about the prepuce. It is more frequent than 
carcinoma of the vagina. It looks like carcinoma of the skin any- 
where. It begins as a small, hard node which breaks down. 
Ulcers result which are elevated above the skin. There is infiltra- 
tion about the ulcers. Then the ulcers grow deeper and the 
inguinal glands become involved. 

Carcinoma vulvae is of two forms, known as (i) cancroid, (2) 
infiltrating carcinoma. 

Cancroid is a new squamous epithelium growth projecting above 
the surface. Degeneration occurs late, with the formation of a 
flat, slowly deepening ulceration with hard edges and infiltrated 
base. It is generally situated on the inner surface of the large 
and small labia and about the clitoris. 

Infiltrating carcinoma is a large hard tumor, with deep extensive 
infiltration and extensive degeneration resulting in an ulcer with 
irregularly infiltrated edges and with a greasy base. Before ulcera- 
tion a diagnosis is difficult. Superficial or deep infiltration, plus 
degeneration, makes the diagnosis. There are then warty, ir- 
regular, productive growths which are hard, especially about the 
base (Winter). 

The conditions from which these affections may have to be differ- 
entiated are the following : 

585 



586 MEDICAL GYNECOLOGY 

Pointed Condylomata. — They are pedicled growths covered 
with squamous epithelium and with a lobulated surface, and in 
some cases may be as large as a cherry, with a thin pedicle and 
lobulated surface. The papillary bodies of the skin have grown 
above the surface and are covered with thickened squamous 
epithelium. There is also connective-tissue papillary overgrowth, 
likewise covered by squamous epithelium. The process is super- 
ficial. There is no growing of epithelial strands deeply into the 
tissue, nor are there independent extensions of epithelial elements. 
Pointed condylomata of the vulva may be present on the large 
labia, especially on the inner side, or on the anterior or posterior 
commissure or on the perineum, or about the anus, and are gener- 
ally the result of a neglected gonorrhea. They may form groups 
of growths of the above character. Pointed condylomata are often 
grouped, especially in pregnancy. They have then a cauliflower 
look and may show surface degeneration. The base is soft and 
degeneration is not deep. There are isolated papillomata in the 
periphery. They are to be diagnosed from carcinoma, but carci- 
noma of this size is eroded, bleeds easily, and degenerates. 

Pointed condylomata are very often found in connection with 
gonorrhea, but not rarely, according to Joseph, after a chancroid. 
These, then, are contagious and produce after cohabitation 
the same form of excrescences on the infected person. Pointed 
condylomata may also occur with non-venereal conditions such as 
purulent or irritative vaginitis or vulvitis. 

Chancre is a red, round ulcer. Its surface is smooth and gives 
off a serous exudation. It is sometimes very small and overlooked. 
The larger ones evidence greater induration and have elevated 
edges. Early benign glandular involvement takes place in the 
inguinal region, followed gradually by an involvement of all the 
glands of the body. 

Broad Condylomata. — Mucous patches, or condylomata lata, 
are round, flat, gray elevations without pedicles. The epidermis on 
the surface is often softened, and sometimes through the loss of 
epidermis may leave a raw surface, especially at the center, as a 
result of which serum exudes. Older patches become rough and 
more warty. They are generally multiple and are usually situated 
on the small labia. Both sides are generally symmetrically in- 
volved by contact inoculation. 



CARCINOMA 587 

Chancroid is an ulcer with undermined elevated edges and no 
infiltration of the base. It occurs from inoculation by another 
chancroid. It is often accompanied by virulent bubo, i. e., in- 
flammatory involvement of related lymphatic glands. There are 
often contact chancroids, i.e., inoculation by a chancroid of a sur- 
face in contact with it. Chancroid may occur on any part of the 
vulva, and may readily infect the hair- follicles. It has a tendency 
to heal from the periphery toward the center. It is generally 
found in puellae publicae. (See p. 436.) 

Tubercular ulcers of the vulva are ulcers situated on the 
small labia and the frenulum and are covered by grayish mem- 
branes. They are of irregular form. The base is composed of 
cheesy tubercles and gray nodules. Tubercle bacilli can be found. 

Ulcus Rodens Vulvae. — On the posterior commissure, near the 
hymen, in the fossa navicularis, and extending into the perineal 
body is an ulceration with sharply outlined edges. The hymen is 
swollen and does not pit on pressure. Deep fistulas result which 
may extend even into the rectum. The rectum is ulcerated. The 
anus is surrounded by edematous blue or white hemorrhoids. The 
large labia are swollen, tense, and do not pit. If this ulceration ex- 
tends higher, the urethra finally becomes destroyed and is surrounded 
by scars. There is edema and ulceration everywhere. The 
whole is characterized by a destructive hypertrophic ulceration. 
This condition is called by some lupus, by others elephantiasis, 
and by others ulcus rodens. Giant cells have been found, and are 
then considered by some as evidence only of a secondary tubercular 
involvement. Ulcus rodens is generally found in puellae publicas, 
and usually in those with a syphilitic history. It is not affected, 
however, by mercury or iodids, which possibly indicates that syph- 
ilitic individuals are very susceptible to this condition, whatever 
its nature may be. Veit considers that a close relation exists be- 
tween ulcus rodens, so-called elephantiasis, and so-called tubercu- 
losis. It may be stated that stricture of the rectum is proof, in a 
differential diagnosis, of the syphilitic nature of a lesion of this 
character. 

Tertiary lues is evidenced by flat ulcerations of productive na- 
ture. The large and small labia and perineum are diffusely thick- 
ened, with resulting non-pitting edema or elephantiasis. The 



588 MEDICAL GYNECOLOGY 

whole has a bronze color and there is ulceration about the external 
meatus. The small labia may be perforated. There is deep in- 
filtration. Characteristic is the flat ulceration with chronic edema. 
The rectum is often stenosed. In other cases the vulva looks red, 
rough, and eaten out without deep ulceration. The lesions are 
especially present around the urethra, perineum, and anus. There 
are pink rough growths, covered with skin, or deep defects or edema 
of the vulva. Sometimes the outer end of the urethra seems lost 
in the nodular eaten-out area, due to degeneration of the infil- 
trated tissues. It is to be diagnosed from tuberculosis or lupus. 
Tuberculosis of the vulva resembles tertiary syphilis. The diag- 
nosis is made by the finding of the tubercle bacilli. Stricture 
of the anus is frequently observed in syphilis. 

CARCINOMA VAGINA 

Carcinoma of the vagina generally takes the form of flat in- 
filtrations which affect part or all of the vaginal wall, especially 
the posterior wall. There is early ulceration of the surface. Oc- 
casionally vaginal carcinoma takes the form of large tumors of 
broad extent filling the lumen of the vagina. They ulcerate late. 
It occasionally takes the form of irregular, papillary, bleeding pro- 
jections lying on the surface and affecting the whole vagina with- 
out deep infiltration. The first form may extend under the mucosa 
gradually and involve the whole length of the vagina, making it 
scarcely passable for one finger. It involves the bladder and 
rectum. Carcinoma of the vagina is characterized by superficial 
infiltration in the form of nodules or flat tumors. Ulceration makes 
the diagnosis certain. 

Sarcoma of the vagina causes flat ulcerating infiltrations or 
rounded tumors covered by mucosa. Sometimes there are grape- 
like bodies, also found in children. Otherwise it is not to be 
diagnosed clinically from carcinoma. 

CARCINOMA OF THE PORTIO 

Carcinoma of the portio, or vaginal portion of the cervix, either 
grows out and projects into the vagina or grows inward and infiltrates 
the portio (Winter). It originates from the squamous covering. 



CARCINOMA 



589 




Fig. 127. — Cauliflower carcinoma of the portio 
vaginalis of the uterus (in longitudinal section) 
(Winter). 



I. The polypoid or cauliflower form either has a broad base 
or is pedicled with a base the thickness of a finger or more, 
and is of the size of a hazelnut up to a fist. The surface is 
irregular, rough, brit- 
tle, and generally cov- «„,.. i^^iltmt 
ered with gangrenous 
masses. If it degen- 
erates slowly, it is 
characterized by in- 
filtration. If it de- 
generates quickly, it 
is characterized by ul- 
ceration. Cauliflower 
carcinoma of the por- 
tio is easily diagnosed 
by the finger and the 
eye. It presents a 

growth in polypoid form on the outer side of the portio. Its sur- 
face degenerates and is rough and brittle. A probe penetrates 

into it easily. Portio carcinoma 
may be flat on its surface. Every 
growth above the surface, especi- 
ally if at first very hard, is ominous 
(Fig. 127). 

II. In the infiltrating form there 
is thickening and hardening of the 
portio. The infiltration extends to 
various depths of the cervix, rarely 
above the fornices. The surface 
shows little loss of substance. 
Sometimes the surface is intact. 
It is then a carcinoma in the sub- 
stance of the portio and therefore 
an infiltrating carcinoma. The 
cervix is like cartilage. The cervix 
is broad, plump, and irregular. The diagnosis, in the presence of a 
hard and smooth surface of the cervix, is difficult. The diagnosis 
is easy when the cervix ulcerates and degenerates (Fig. 128). 




Fig. 128. — Infiltrating carcinoma 
of the portio. The carcinoma infil- 
trates one lip and the neighboring 
fornix, but is still covered by intact 
squamous mucosa (Winter). 



590 



MEDICAL GYNECOLOGY 




Fig. 129 
matous cavity in 
portio (Winter). 



Carcino- 



the 



III. Carcinomatous cavity. There is a funnel-shaped hole in 
the cervix resulting from ulceration and generally situated in one 
lip. The hole runs parallel to the cervical 
canal or extends into it (Fig. 129). 

IV. Carcinomatous ulcer or ulcus rodens 
is a flat ulceration on the cervix with no 
tendency to extend into the depth of the cer- 
vix, but with a tendency to extend super- 
ficially, generally on one lip. It spreads to 
the fornices and vagina, rarely into the cer- 
vical canal (Fig. 130). 

Ulcerative carcinoma on the portio is recog- 
nized if a depression is formed, with uneven, 
rough, degenerated wall and hard surround- 
ing tissue. If the depression is only slight, we 
depend on the eye to recognize degeneration. 
The polypoid form and ulcus rodens have 
a greater tendency to spread to the vagina, 
and do so, superficially. The others spread into the vagina through 
the submucous tissue and represent infiltrations in the vagina 
covered by mucosa, which in- 
filtrations may extend down to 
the introitus. The infiltrating 
form and the carcinomatous 
cavity rarely extend above the 
internal os. They involve the 
connective tissue, that is, the 
parametrium, generally poste- 
riorly and laterally. Bladder 
and rectum are seldom reached. 
Carcinoma of the portio takes 
its origin from the squamous 
epithelium or from erosions. 

Carcinoma of the portio oc- 
curs in different forms, accord- 
ing as it takes its origin from the 

squamous epithelium or from erosions. The form which comes from 
the squamous epithelium is called cancroid. The form which comes 




Fig. 130. — Carcinomatous ulcer, or 
ulcus rodens, on the posterior lip and 
the neighboring fornix (Winter). 



CARCINOMA 591 

from the erosions may be squamous in character, due to a meta- 
plasia of the cylindrical epithelium, or there may be no metaplasia. 

Clinically carcinomata of the portio are either ulcers or cauli- 
flower tumors. 

Carcinomatous ulcers of the portio have a hard infiltrated per- 
iphery with a greasy base. In the early stages they may be mis- 
taken for chancre. These ulcers may occur on one or both lips 
of the cervix or around the external os. They may have grown 
deeply, leaving the surface relatively intact and forming round 
nodes in the tissue. When these break down, the surface is 
destroyed and little cavities occur in the portio. 

In a differential diagnosis the following conditions must be con- 
sidered : 

Pointed Condylomata of the Cervix. — In pregnancy they 
may be very close together and may form a circumscribed tumor 
on the external surface of the cervix and give the portio an irregu- 
ular papillary surface. The base is not infiltrated, there is no 
real ulcer, they look whitish-red, and others may be found in the 
vagina and on the vulva. 

Ulcus simplex hemorrhagicum is not large, is sharply out- 
lined but not very deep. There is small-celled infiltration with 
dilated vessels. There is no epithelium on its surface and very few 
glands, if any. The cause is not known. 

Erosions are situated around the external os; have a very red 
color and a shiny surface, no sharp outlines; there are often fol- 
licles on the cervix. There is cervical catarrh. If clean, they are 
easily diagnosed from carcinoma, with the possible exception of that 
form known as erosio-papillaris with rough surface. If the surface 
becomes infected and covered with a membrane, it is often hard to 
diagnose from a carcinoma except by microscopic examination of 
an excised bit. 

Erosion ulcers are different from erosions and are distinguished 
by the microscope as follows: Erosion glands with cervical cyl- 
indrical epithelium in them lie in small- celled infiltrated tissue 
which is rich in vessels. The tissue of the portio is deeply in- 
filtrated by glands. Through local treatment, injections, etc., 
there results a loss of substance. There is diffuse infiltration and a 
development of the large vessels. 



59 2 MEDICAL GYNECOLOGY 

Decubitus Ulcer. — When due to the presence of a pessary, it 
is situated directly on the spot where the pessary presses. It has 
a sharp border and ulcerative base. The base, however, is not 
infiltrated and heals easily. It is generally not immediately about 
the external os. It is also frequently present with prolapse of the 
uterus. It then shows a large loss of substance on the cervix ex- 
tending into the vagina. 

Chancre in the early stages is hard to differentiate. Later on 
it is a flat ulcer with an infiltrated cartilaginous base, sharply out- 
lined and covered by adherent yellowish-gray membrane, and may 
be single or multiple. The spirochete pallidum is to be found. 
Constitutional symptoms result. 

Mucous patches are white or yellow and elevated with degen- 
erated surface and multiple. They are also present in the vagina 
and vulva, where they are not ulcerated. 

Gummatous ulceration is situated near the external os, often 
affecting both lips, and is sharply outlined. There is a yellow 
covering over bleeding granulations. Gummatous ulceration 
breaks down slowly. There is a crater-like deepening. There 
is peripheral extension with serpiginous outline. 

Ulcus Molle. — Soft chancre is a rapidly spreading ulcer with 
punched-out, elevated, undermined edges. The base is not infil- 
trated. Membranous spots are on its surface. Such ulcers are 
often multiple. Contact ulcers are present and other ulcers in 
the vagina and on the external genitalia are noted. 

Tuberculous Ulcer. — Ulcer with undermined edges, partly 
sclerosed. Situated about the external os. Yellow irregular base 
which is not infiltrated. Microscope shows small-celled infiltra- 
tion area with degeneration and detritus. By microscope many 
giant cells are found. Finding tubercle bacilli makes the diagnosis. 

Ulcerative Carcinoma of the Portio. — If superficial, it is 
hard to diagnose. It has a yellowish-gray surface which is irreg- 
ular and papillary. The base is infiltrated and the character of 
the ulceration conveys the impression of loss of substance. If 
deep, there is seen an ulcer with an uneven, rough, destroyed base. 
There is infiltration about it. Evidences of degeneration and 
destruction are present. It can be easily penetrated by the sound 
or finger. One can easily tear off the fragile tissue with the finger. 
Such brittleness of tissue is always suggestive of carcinoma. 



CARCINOMA 



593 




Fig. 131. — Infil- 
trating carcinoma of 
the cervix (Winter). 



CARCINOMA OF THE CERVIX 
A carcinoma which starts from the lining of the cervix may, 
like some cases of carcinoma which start from erosions, show a 
change of the cylindrical epithelium to squa- 
mous epithelium with solid cell groups invading 
the cervical wall. On the other hand, the glands 
of the cervix generally produce a growth of cyl- 
indrical eipthelium resulting in an adenoma- 
tous carcinoma. Clinically, cervix carcinoma is 
often a polypoid tumor starting from a benign 
mucous polyp. In other cases the wall of the 
cervix is diffusely infiltrated, and when degen- 
eration occurs a large cavity is present. 

Infiltrating Carcinoma. — There is an infil- 
tration in the cervix formed through a thickening 
of the wall. There is little tendency to ulceration . 
It is simply a large nodule covered with intact 
mucosa till the latter becomes thinned out and 
infected. The mucosa remains long intact. Infiltrating carcinoma 
is hard to diagnose. The cervix is infiltrated but still covered with 

mucosa. The cervix is enlarged, 
thick and plump, hard as cartilage, 
but often elastic. As the carcinoma 
approaches the external os, we may 
see yellow points of degeneration 
and can easily rub off the superfi- 
cial areas. When the carcinoma 
approaches still nearer, it breaks 
down and looks like a primary por- 
tio carcinoma. It is easy to over- 
look this growth if it is in the cer- 
vical canal and above the external 
os. It is to be diagnosed from 
metritis colli and follicular hyper- 
trophy, from interstitial myoma, 
and from chronic cervical catarrh 
of older women. The curet and microscopic examination are 
then necessary to aid in the diagnosis (Fig. 131). 
38 




Fig. 132. — Carcinomatous cavity 
in the cervix, occurring through de- 
generation of an infiltrating carcin- 
oma (Winter). 



594 



MEDICAL GYNECOLOGY 



Metritis colli with lacerations may resemble an infiltrating carci- 
noma, but the whole cervix is usually involved. There is a sur- 
face of smooth mucosa. The resemblance to carcinoma is marked 
if the portio is filled with dilated follicles. 

Follicular Hypertrophy of the Cervix. — There is a smooth cover- 
ing of the portio, through which we see dilated follicles. The 
surface is not rough or papillary, the consistence is not brittle. 
Follicular hypertrophy of the cervix is distinguished from carci- 
noma by the presence of dilated erosion glands. Under the mi- 
croscope the epithelium in the follicles 
of Naboth is of a single layer and 
cubical. 

Carcinomatous- Cavity. — This fol- 
lows degeneration of the infiltrating car- 
cinoma (Fig. 132). 

Ulcerative carcinoma involves the 
cervical canal superficially. It does not 
grow deep, but it degenerates quickly, 
therefore a large space is formed with a 
thin wall which is not infiltrated (Fig. 

Those carcinomata in the cervical 
canal which by ulceration have opened 
out upon the external surface of the por- 
tio are diagnosed by the rough, raw, brittle 
walls of the cavity, especially if there is infiltration of the sur- 
rounding tissue. If the finger can enter the cervical canal, it feels 
the irregular thickness and the rough surface with a fragile, brittle 
consistency. If the curet is used in the cervix and very gently 
applied, much tissue can be removed, and the diagnosis of carcin- 
oma is then beyond doubt. These forms may extend into the vagina, 
but may also involve the vagina under the mucosa by infiltration. 
They readily involve the parametrium. The bladder is involved 
early, the rectum late. 




Fig. 133. — Ulcerating car- 
cinoma, with destruction of 
almost the entire cervical 
canal (Winter). 



CARCINOMA OF THE FUNDUS 

Carcinoma of the fundus starts from the mucous membrane 
and includes the so-called adenomatous carcinoma, formerly often 



CARCINOMA 



595 




Fig. 134. — Dif- 
fuse carcinoma of the 
fundus uteri (Win- 
ter). 



called adenoma malignum. This is now considered as genuine 
carcinoma. Carcinoma of the corpus may begin from a mucous 
polyp. Uterine carcinoma may be circum- 
scribed, or it may be diffuse. 

I. The Diffuse Form. — Carcinoma of the 
fundus comes from the uterine mucosa. The 
diffuse form affects the whole mucosa and pro- 
duces irregular thickenings and villous out- 
growths with infiltration of the wall and thick- 
ening of the whole uterus. It finally grows 
through the entire wall (Fig. 134). 

II. The Circumscribed Form. — Like I, 
only circumscribed (Fig. 135). 

III. The Polypoid Form. — The polypoid, 
thin-pedicled form is rare. There is a polyp 
filling the uterine cavity which is soft, brittle, 
and degenerating. It may grow externally into 
the wall or internally into the uterine cavity. 

The only parametrial tissue which becomes involved is the 
ligamentum latum. The peritoneum be- 
comes involved by growth of the carcin- 
oma through the uterine wall. Metastases 
into the ovaries occur. 



CHARACTERISTICS OF CERVTCO- 
UTERINE CARCINOMA 

Carcinoma of the uterus has a tendency 
to superficial degeneration. It furnishes, 
therefore, an excellent medium for the 
growth of micro-organisms, which include 
not only saprophytes but also streptococci 
and other pathogenic organisms. This 
explains the fever occurring with carcin- 
oma. This destruction of carcinoma re- 
sults in arrosion of the blood-vessels and 
explains the characteristic bleeding which occurs on coitus, on ex- 
amination, or independently. 




Fig. 135. — Circum- 
scribed carcinoma of the 
fundus uteri (Winter). 



596 MEDICAL GYNECOLOGY 

Carcinoma of the cervix or of the corpus may extend upward or 
downward and by direct continuity involve the entire uterus. In 
addition, cervix carcinoma may produce metastases in the fundus 
and a fundus carcinoma may produce metastases in the cervix. 
Frequently there occur implantation metastases in the vagina 
through direct implantation of cast-off cells or through retrograde 
lymphatic extension. Carcinoma readily grows through the 
uterine wall, especially carcinoma of the cervix, and readily enters 
into the connective-tissue parametrium. This may involve the 
ureters, or the bladder, or the recto-uterine space, or the general 
peritoneum. In the end-stage of a uterine carcinoma there is a 
complete filling of the small pelvis with a firm mass in which the 
various organs cannot be differentiated, resulting in compression 
of the rectum and ureters and the formation of fistulas. Earlier 
than the occurrence of direct growth into surrounding tissue there 
occur metastases into distant structures through lymph- channels. 
Involvement of the lymph-glands of the pelvis may occur in the 
very early stages (Winter). 

1. Carcinoma of the portio involves the hypogastric lymph- 
glands situated between the external iliac artery and the hypo- 
gastric. A few lymph-glands in the ligamentum latum, situated 
where the uterine artery and the ureter cross, are often involved 
early. The internal inguinal glands are involved early. 

2. Carcinoma of the cervix. In addition to the hypogastric 
and internal inguinal glands, the internal sacral glands between 
the hypogastric artery and the rectum, as well as the external 
iliac glands situated external to the external iliac artery, are 
involved. 

3. Carcinoma of the fundus involves the external iliac glands and 
the inferior lumbar glands situated on the common iliac artery, 
and the superior lumbar glands situated near the lower end of the 
aorta. In advanced cases all these glands and other glands up to 
the diaphragm may be involved and metastases may occur in any 
of the organs of the body. Lymph-glands are often swollen with- 
out their being infiltrated by carcinoma. This inflammatory in- 
volvement of the glands may be caused by the numerous micro- 
organisms present in the carcinoma. 

Most malignant is carcinoma of the cervix, because it spreads 



CARCINOMA 597 

readily through the uterus and involves the lymph- channels and 
paramatrium. Carcinoma of the portio is almost as dangerous. 
Least hopeless is carcinoma of the corpus, because involvement 
of the lymph-channels and broad ligaments occurs late. 

The majority of cases of carcinoma occur in women who have 
borne children. Hofmeier found only 5 per cent., out of eight 
hundred and twelve cases, in women who had not borne children. 
The average number of labors was eight. 

SYMPTOMS OF CARCINOMA OF THE PORTIO, CERVIX, AND 

UTERUS 

Two important symptoms of portio carcinoma are bleeding on 
cohabitation and post-climacteric hemorrhage, especially when 
coming on several months after menopause (exclude myoma, 
polyps, disease of the vessels and tender senile endometrium). 
Another symptom is irregular bleeding. Another symptom is 
discharge, either foul, bloody, and mixed with tissue particles, 
or sero-sanguineous, like meat-juice. The diagnosis depends on 
the evidence of new-growth and infiltration plus degeneration. 

The symptoms of carcinoma of the cervix are not characteristic 
in the early stages. In older women menstruation has generally 
ceased and then recurs. In other cases menstruation does not 
cease, but continues abundantly. Often the first symptom is 
bleeding on coitus. The loss of blood at first may take the type 
of menstruation, but is abundant. Then bleeding occurs ir- 
regularly on coitus, on the performance of any act involving effort, 
or with the straining at stool associated with constipation. There 
is usually a loss of mucus stained with blood. Characteristic is 
the disagreeable odor and the thick, brown character of the blood. 
This is usually due to superficial degeneration of the carcinoma. 

Pain may be absent entirely until toward the end. Sometimes 
it is present in the beginning. Some patients complain of back- 
ache, while others complain of peritoneal irritation. Then comes 
cachexia, loss of weight and strength. If the bladder is infiltrated, 
there is frequency of urination and painful urination. If the 
rectum is involved, there is tenesmus and difficulty in passing 
feces. Hemorrhoidal bleeding and pain in the anus are noted. 
Patients often complain of sleeplessness and restlessness, and 



598 MEDICAL GYNECOLOGY 

especially marked is the loss of appetite. Not infrequently sexual 
desire is increased. 

In the very early stages the diagnosis can be made only by micro- 
scopic examination. It is of the greatest importance to make a 
test excision in every suspicious case, because the clinical symptoms 
resemble those of chronic metritis, of erosions of the cervix with 
hypertrophy of the cervix, and of ulcers of various forms. Winter 
finds the cystoscope of great importance in diagnosing infiltration 
of the precervical connective tissue. However, the projection of 
the trigone, swellings of the mucous membrane of the bladder, 
hemorrhage in the mucosa, oedema bullosum, changes in the open- 
ings of the ureters, and papillary excrescences all resemble closely 
the same changes occurring in precervical inflammation due to 
bacterial involvement. 

Corpus carcinoma occurs in the proportion of 10 per cent, of 
cases of uterine carcinoma. It occurs most frequently during and 
beyond the menopause. " Chronic endometritis with long-con- 
tinued profuse menstruation" is a frequent history. Corpus car- 
cinoma is characterized by its gradual development. It has been 
observed to be confined to the body of the uterus for five years. 
This tendency to very late spreading into the parametrium explains 
the good results obtained by early operation. 

The symptoms of corpus carcinoma include: (1) A long con- 
tinuation and a profuse character of menstruation. The recur- 
rence of menstruation after a shorter or longer period of cessation is 
a symptom of great importance. (2) An additional symptom of 
importance is the discharge of watery fluid, later taking on the 
character of meat extract, and finally becoming purulent and foul- 
smelling. When degeneration occurs the discharge is extremely 
disagreeable. (3) The third symptom is pain in the back and legs 
and severe pain in the abdomen. Almost pathognomonic when 
they do occur, are colicky pains occurring at certain hours of the 
day and finally ending in a foul bloody discharge containing tissue 
detritus. Not infrequently there occurs peritoneal pain through 
extension of the carcinoma under the serosa. The uterus is often 
enlarged. Carcinoma of the fundus occurs in the majority of 
cases beyond the climacterium. It is not to be diagnosed by 
bimanual findings. Irregular bleeding, sero-sanguineous flow, 



CARCINOMA 599 

especially if fetid, and intermittent uterine colic are the symptoms. 
In the early stages the uterus is normal. In the later stages the 
uterus is thicker, larger, and irregular, as with myoma or metritis. 
The repeated examination of scrapings is essential. The history of 
a return of menstruation plus the discharge and the pain, added 
to the size, hardness, and irregular feel of the uterus, distinguish 
a carcinoma from a myoma. 

It is to be diagnosed by examining the cavity. Curet the whole 
endometrium for examination by microscope. Examination with 
the ringer shows new-growth plus degeneration. There is a cir- 
cumscribed or diffuse, hard, infiltrating thickening, or else the in- 
filtration of a carcinomatous ulcer is felt or else papillary growths 
or brittle tumors are noted. 

If the carcinoma does not remain limited to the uterus, there is 
local extension to the vagina, parametrium, bladder, and rectum. 

The neglect, on the part of patients, to consult physicians on the 
first appearance of bloody or sero-sanguineous discharge, especially 
at the climacteric age or after menopause; the failure, on the part 
of physicians, to make a thorough bimanual and tactile examination, 
and to examine thoroughly with the aid of a speculum and the use 
of the sound ; the failure to make test excisions and test curettings 
for the purpose of microscopic examination; the failure to consider 
all cases at this period and even much earlier as malignant unless 
another diagnosis can be positively made; all these are factors in 
making cervico-uterine carcinoma the almost hopeless disease that 
it is. Cervical carcinoma, situated in an area surrounded by the 
six connective-tissue ligaments and by additional connective tissue, 
all rich in lymphatics (especially the broad ligaments), is such a 
dangerous disease because of the readiness with which secondary 
extrusions of the malignant process invade the periuterine tissues. 
Were these cervical carcinomata seen before such invasion of the 
surrounding tissues and before invasion of the pelvic glands, carcin- 
oma would furnish immeasurably better results and recurrences 
would be markedly fewer in number. Carcinoma of the fundus 
invades the blood ligaments very late because the amount of lymph- 
atic connective tissue in the upper part of the broad ligament is 
slight. In the lower half of the broad ligament the lymphatic 
supply is abundant. Yet in this lower area of the uterus, in the 



6oO MEDICAL GYNECOLOGY 

cervix whose outer covering is exposed to the eye and whose canal 
is so readily entered by the sound or curet, that is, in that part of 
the uterus which nature has selected for the location of the largest 
number and the most malignant of uterine carcinomata, the de- 
velopment of carcinoma is not looked for nor recognized with the 
frequency that is possible nor with the care and attention that con- 
stitute a duty. Carcinoma of the uterus has a mortality which can 
be reduced immeasurably, if these facts are taken to heart and if 
the laity are made aware of the meaning of the premonitory symp- 
toms of irregular bleeding and sero-sauguineous or disagreeable 
discharge, especially when either of these symptoms occur at the 
menopause age or after the amenorrhea of the climacterium. 



TREATMENT 

Therapy consists in total extirpation of the uterus, ovaries, tubes, 
broad ligament, pelvic connective tissue, and of enlarged retro- 
peritoneal glands. As regards prognosis, Winter finds in 53 per 
cent, permanent cure by radical operation in favorable operable 
cases. If radical operation cannot be done, local treatment may 
keep the patient in a comfortable state for a long period. 

In the treatment of inoperable cervical or uterine carcinoma the 
degenerated tissue should be removed with a curet or with a sharp 
spoon. Care is necessary not to invade the bladder, the rectum, 
and the cul-de-sac of Douglas. The denuded bleeding area of the 
cervix is then cauterized with a Paquelin or with the electric cautery, 
gently applied, not so much for the effect of actual contact of the 
cautery, as for the effect produced by the heat. In place of the 
cautery pure nitric acid may be used. The resulting cavity is then 
packed with cotton, covered with tannic acid and iodoform equal 
parts, and the vagina is packed with sterile gauze. These are left 
in place for three days. 

Martin recommends the use of cotton soaked in pure liquor ferri 
sesquichlorati i or packing the cavity in the cervix after the previous 
cauterization. These procedures are to be renewed after the 
lapse of weeks or months if the injury to the bladder, rectum, 
and peritoneum can be avoided. For the discharge, douches of 
lysol or carbolic acid or thymol are of value. Peroxid of hydro- 



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CHORIOEPITHELIOMA 

A fecundated ovum embeds itself in the lining of the uterus 
through centrifugal descent. The ovum then causes a reaction in 
the surrounding tissue, and a dilatation of the surrounding lymph- 
spaces, so that a resulting localized edema takes place. In addi- 
tion, a dilatation of the capillaries is produced. 

The Trophoblast. — The outer layer of the ovum develops into 
what is known as the trophoblast, which is a product of the ecto- 
derm, and from it develop the cells of Langhans and the syncytium. 

Shortly after the ovum is embedded in the mucosa a connection 
between the trophoblast and the maternal blood takes place through 
a rupture of the capillaries. The maternal blood then bathes the 
ectodermal trophoblast. This opening of the maternal vessels oc- 
curs, however, before the formation of villi; and the cells of the 
trophoblast may therefore enter the maternal veins at the very 
earliest period. 

A gradual transition of trophoblast cells into syncytial cells, 
and a gradual change of trophoblast nuclei to syncytial nuclei, 
take place through the corrosive action of the maternal blood, and 
elements of maternal blood aid in forming the syncytial proto- 
plasm. The syncytium does not originate from the maternal 
endothelium, or from the uterine epithelium, or from the decidua 
cells (Fig. 126). 

Just as in the early stages the trophoblast invades the decidua, 
so after the formation of villi the future course of the ectodermal 
trophoblast and of the syncytial cells is of a destructive character, so 
far as the decidua is concerned. The trophoblast and syncytium 
invade the maternal tissue and mingle with it. They infiltrate the 
decidua and bring it to destruction. The trophoblast and syncy- 
tial cells erode the capillaries and blood-vessels, the blood in turn 
changing fetal cells to syncytium. 

The invading trophoblast and syncytial cells have at all times 
a great power of wandering. They enter between bundles of 
muscular and connective tissue, into the lymph-spaces and into the 

602 



CHORIOEPITHELIOMA 603 

blood-vessels. At full term the uterine wall is infiltrated with 
fetal cells of a syncytial character. 

From the very earliest moment fetal cells are continually enter- 
ing the blood of the mother, not only in the primary intervillous 
space, but in the fully formed intervillous space, as well as through 
the vessels of the uterine decidua and wall. 

Characteristics of Chorioepithelioma. — There have been ob- 
served and reported several hundred cases of a uterine growth of 
exceedingly malignant character, occurring after abortion, hydatid 
mole, and labor, or even after tubal abortion. 

The clinical symptoms are : (i) Pronounced uterine hemorrhage, 
recurring even after repeated curettings; (2) very early metastases, 
especially in the lungs and vagina; and (3) early death through 
hemorrhage, cachexia, or septic infection. 

Macroscopically, these tumors are more or less localized, ul- 
cerating, degenerating, hemorrhagic growths, frequently passing 
deeply into the uterine wall, or through it with involvement of the 
peritoneum. 

Microscopically, these tumors are characterized by hemorrhagic 
areas, areas of degeneration, the presence of fibrin, and the in- 
volvement and invasion of capillaries and large vessels. They 
are especially characterized by the presence of (1) pale round and 
polygonal cells with pale protoplasm and pale nucleus, and (2) 
large round and spindle-shaped cells with dark nuclei, and also 
(3) large, irregular branches composed of multinuclear proto- 
plasmic masses (syncytium). 

These typical growths have been variously described as sar- 
coma, carcinoma, carcinoma after abortion and labor, and as 
sarcoma causing abortion. 

Sanger, in reviewing these cases, found a decided resemblance 
in their characteristic elements, and came to the conclusion that 
the decidua cells were the cause of the growth, giving it then the 
name decidual sarcoma or decidua malignum. 

As a result of the investigations of Fraenkel, and later of Mar- 
chand, attention was called to the fact that those cells which so 
closely resembled decidua cells were really of fetal origin, and were, 
in fact, the cells of Langhans, while the spindle-shaped and grouped 
masses of multinuclear protoplasm were of syncytial origin. 



604 MEDICAL GYNECOLOGY 

From all sides, especially in England and Germany, this view 
was attacked. It was pointed out how baseless was the state- 
ment that fetal cells could produce a growth of this malignant 
character, differing from carcinoma only in the fact that metastases 
resulted through the blood- channels instead of through the lymph- 
channels. 

A few years ago the controversy was not entirely settled, many 
holding the view that these tumors were sarcomata and originated 
from the decidua cells. The giant cells and the protoplasmatic 
masses were referred, likewise, to changes in the decidua. Others 
held that these growths result from the epithelial covering of the 
villi. That these cells, if they are of fetal origin, should be mis- 
taken for decidua cells is a natural error, for we know that even in 
the normal processes a positive distinction is often very difficult. 
It is to be noted that many investigators have mistaken the typical 
trophoblast cells in tubal placentation, too, for decidua cells. Still 
others leaned to the view that the stroma of the villi plays a part. 

On the other hand, among those who hold that these growths 
originate from the chorionic covering, a division of sentiment ex- 
isted, for those who consider the syncytium and cells of Langhans 
to be of uterine origin classed these growths as carcinoma and 
sarcoma of a somewhat atypical character. Those who believed, 
as we have shown, that the eipthelial covering of the villi is of 
fetal ectodermal origin, and who also classed these tumors under 
the category of carcinoma, have introduced into pathology a new 
element. ("Uterine and Tubal Gestation," Wm. Wood &Co., 1903.) 

A factor which has served to clear our views in these various 
disputed points is the knowledge that 50 per cent, of these malig- 
nant uterine growths, commonly known as deciduoma, follow the 
presence of hydatid mole. 

Histopathology of Chorioepithelioma. — In hydatid mole we 
find the same elements as in normal placentation, only that these 
elements are excessive in number and size. Hydatid mole rep- 
resents a hypertrophic growth of the chorionic covering, accom- 
panied by dropsical swelling of the chorionic stroma. As is well 
known, the covering of the villi consists of two layers — an outer, 
syncytium, and an inner, the cell layer of Langhans. The growth 
concerns both the syncytium and the cell layer of Langhans. The 



i • 






ft 



s-5 5 ■■' ■■ • 

IS 






■ 



?\ Jfi "S-S », .-3 












- 



ft. Hi. 



Large syncytial cells with 
large nuclei 



Fig. 136. — Low-power drawing of the typical form of chorioepithelioma, show- 
ing the uterine wall invaded by chorionic elements. X, X, X, three areas of dense 
connective tissue surrounded by chorionic epithelial elements and resembling 
chorionic villi. Y, connective tissue center surrounded by polynuclear syncytial 
mass of considerable thickness, probably a villus. 



CHORIOEPITHELIOMA 605 

abnormal element is the occurrence of very large cells with immense 
nuclei in large number, and a decided growth of the syncytium, ac- 
companied by the formation in the latter of large vacuoles. 

Leaving out of consideration those cases malignant because of 
the diffuse and deep infiltration of the uterine wall by the cystic 
villi, by no means are all hydatid moles of a malignant character. 
A method of distinguishing between the benign and malignant 
cases was proposed by Neumann. He observed in three cases 
subsequently resulting in the so-called deciduoma, large cell ele- 
ments in the stroma of numerous villi, which he considered to be 
infiltrating elements of the syncytium. He observed, further, an 
abnormal infiltration of cell groups through such syncytial elements. 
But investigation of subsequent cases shows that malignant forms 
are not always preceded by such changes in the hydatid mole, 
while others have found these changes and yet no malignant growth 
has occurred. 

Even the occurrence of metastases is no proof of malignancy, 
for Pick reported a case with a metastasis of villi in the vagina, 
and yet the patient recovered. We know that fetal cells are given 
off at all stages from the normal placenta into the maternal cir- 
culation. Even the normal placenta, as Pick believes, may give 
off metastases of villi, and these may (i) degenerate, or (2) grow 
slightly, or (3) produce the same syncytial growth as is observed 
in benign hydatid mole; and (4) primary malignant growths may 
originate, and have originated, from such metastases. 

Typical and Atypical Forms. — Under chorioepithelioma we 
distinguish two forms, the typical and atypical. In the typical 
forms we find large, round, polyhedral cells, with strikingly large, 
very irregular, lobulated nuclei, which stain very deeply and often 
degenerate, forming vacuoles. The protoplasm is relatively scanty. 
These cells are capable of great wandering and are found more 
or less isolated between the muscle and the connective-tissue 
bundles, in the lymph-spaces, and in the vessels. They form 
the advance guard in the way of infiltration. There are, further, 
irregular bridges of protoplasm containing scattered or grouped 
nuclei of various sizes. 

Many of these groups of nuclei are the same large, irregular, 
lobulated nuclei as were observed in the form just mentioned. 



606 MEDICAL GYNECOLOGY 

In addition are found irregular masses of protoplasm containing 
many small nuclei. The character of the latter is identical with 
normal syncytium. 

The irregular groups of protoplasm containing grouped nuclei 
of various sizes are undoubtedly of syncytial character, for they 
result through the blood surrounding and infiltrating the cells of 
Langhans, and it is very evident that these cells form the afore- 
mentioned grape-like nuclei. The isolated large cells are like- 
wise of syncytial character. They have generally been mistaken 
for decidua cells. They may be distinguished from the cells of 
Langhans, for the latter are pale, polyhedral groups of distinctly 
epithelial character. They are rich in glycogen, and therefore 
often contain vacuoles. The nuclei are large but pale. 

The cells of Langhans are illustrated in the atypical form, where 
the syncytial elements are relatively in the background. In fact, 
no more and no different syncytial cells are present than in normal 
gestation. The trophoblast cells lie closely grouped and sur- 
rounded by syncytial elements in quite the same manner as in 
normal gestation, or especially in tubal gestation. They are poly- 
gonal cells, concerning which different views have been held. They 
have been called decidua cells. No vessels of their own, however, 
are present in these epithelium-like groups, and their character, 
their structure, and their arrangement so closely resemble the 
trophoblast cells observed in normal gestation that any other view 
is not to be considered. These epithelium-like cells and the 
syncytial masses of various forms all originate from the trophoblast 
cells. 

Fetal Origin of the Tumor. — In these growths newly formed 
villi have not yet been found — a proof of the limited power of 
differentiation possessed by the trophoblast cells alone when act- 
ing apart from a living ovum and without the presence of meso- 
derm. It may be said, therefore, that two forms of this tumor 
exist, the first typical, the second atypical. The former cases are 
so characteristic that they cannot be mistaken. The latter have 
been so frequently called carcinoma by eminent authorities that 
my belief that many of these are overlooked and incorrectly diag- 
nosticated is certainly correct. 

A study of the histology of so-called deciduomata, and a com- 



Uterine tissue' 



Syncytial si run J 






Polynuclear syncytial _ 
mass with vacuoles 






.._ 



-V- 






Polynuclear 
syncytial mass ■ 
without vacuoles 



. 







& 



■ 






J" 









: * 



*V- 






Fig. 137. — Upper left-hand corner of Fig. 136 highly magnified, showing the 
character of the polynuclear syncytial masses. Along the right and lower borders 
are larger isolated mononuclear syncytial cells. 



*f*Z 






Syncytial 
strand 



Vacuole 
containing 



■ 






■ ' 




■ 



S.*^ 



e , 






o r 



Vacuole 
lined with 
fiat endothe- 
lial cells 



Blood and Troplioblasl cells forming 
blood-cells syncytial masses 

Fig. 138. — Highly magnified area of Fig. 137 showing finer characteristics of 
syncytial masses. Change of trophoblast cells en masse into polynuclear, vacuolar 
structures. 



CHORIOEPITHELIOMA 607 

parison of their structure with the structure of normal placental 
elements, prove these tumors to be fetal in origin. The cells from 
which they develop are the cells which cover the chorionic villi. 
Since these are epithelial in character, these tumors, belonging as 
they do to the most malignant form, should be called chorio- 
epithelioma. 

Characteristics of the Growth of the Tumor. — We have, 
then, in the chorioepithelioma a reproduction of the same con- 
stituent elements as are found in normal placentation and as are 
observed in benign and malignant cases of hydatid mole. These 
cells exert the same influence and effect on the maternal tissues as 
do the fetal cells in a normal uninterrupted pregnancy. 

They invade, as do the normal trophoblast cells, the maternal 
decidua and destroy it. They infiltrate and erode the walls of the 
vessels. They invade and infiltrate deeply, too, the uterine wall. 
They advance, either as distinct Langhans or trophoblast cells, 
or as syncytial cells, or else they undergo in their advance a change 
form the former to the latter, especially when in contact with mater- 
nal blood, as in the case of placentation, either uterine or tubal. 

Their invasion of the maternal vessels and capillaries gives them, 
from their earliest existence as malignant cells, the opportunity of 
invading the maternal circulation, with a resulting early formation 
of metastases. Their ability to erode the vessels causes profuse 
and constant bleeding. Their ability to destroy the maternal 
tissue as they advance produces larger and smaller areas of de- 
generation and necrosis accompanied by the presence of much 
fibrin. These cells preserve their ability to grow when they reach 
their new locations, with the result that they produce in the various 
organs, but most frequently in the vagina, malignant nodules of 
the same character as the parent growth. In fact, these secondary 
nodules have in some cases been observed before the character of 
the uterine symptoms has called attention to the presence of 
malignant conditions in the uterus. 

The fetal cells producing a chorioma are situated in the most 
favorable surroundings. They have been performing practically 
malignant functions in that they have destroyed, even during 
normal placentation, maternal tissues, have invaded maternal 
vessels, and have been carried off into the maternal circulation. 



608 MEDICAL GYNECOLOGY 

When connected as part and parcel of an ovum, when feeding and 
nourishing the fetus with the products of the maternal blood which 
have passed through them, they are, so to speak, under control of 
the parent organism, the ovum; yet when released from this 
connection they continue an independent growth of their own. It 
is quite probable that in hydatid mole the edematous swelling of 
the chorionic stroma is due to interference with the proper ex- 
change between the fetus and the mother, due to a more or less 
increased and independent growth on the part of those cells whose 
function it is, normally, to aid and permit of this exchange. It is 
likewise probable that the growth of the chorionic cells in chorio- 
epithelioma takes place during the pregnancy and is often the 
cause than the result of abortion. 

The Relation of Ovarian Secretion to Chorioepithelioma. — 
We have observed in the development and change of trophoblast 
cells to syncytium that the closely grouped cells, when vascularized, 
change to plasmodial or syncytial cells. That the blood of the 
mother furnishes the greater portion of the protoplasm of these 
syncytial cells has been clearly shown. Therefore their produc- 
tion and growth, even in normal conditions, depend upon their 
taking up directly from the mother elements essential for the forma- 
tion of protoplasm, while the trophoblast cells themselves furnish 
the nuclei. Therefore the growth of so pathologic a tumor as a 
chorioepithelioma is not absolutely a reproduction of fetal cells, but 
is in a more or less direct manner a direct maternal production also. 

The invasion and destruction of maternal tissues in normal 
gestation occurs within certain fixed limits, and the fetal cells en- 
tering the maternal circulation undergo no further growth. What 
preserves this balance? What limits and controls the potential 
of the parasitic fetal cells? In hydatid mole, and especially in 
chorioepithelioma, the fetal cells are no longer held in check, and 
they possess the power of unlimited growth. What has upset the 
normal balance? 

When the fecundated ovum enters the uterus it destroys the 
surface epithelium under it and descends actively into the decidua. 
It produces a decided reaction in its immediate circumference, so 
that even in its earliest stages it evidences a biochemical power. 
When the natural blood makes its exit from the capillaries, it ought 



m * 



Giant cell 

with granular. 

nucleus 



% * 



<®" 




Trophoblast 
cell 


f '& ■ V S 


'* 

*- • 


fcf 


i 







Fig. 139. — Highly magnified area of Fig. 136 showing character of isolated 
mononuclear giant syncytial cells and the infiltration by them of the uterine tissue 
and lymph spaces. 



Pale epithelioid cells- 



4:. - 

\i • \ ■ Trophoblast cells 



ft ft I ,•/ 



"T Island 0} cells 



>f t .''- ^ __J -s . , 

*& -■•■ # • 



Syncytial cells 



Fig. 140. — High-power drawing of atypical chorioepithelioma greatly resembling 

carcinoma. 



CHORIOEPITHELIOMA 609 

to coagulate but does not. It circulates against the fetal cells 
which have the power to prevent coagulation. The trophoblast and 
syncytial cells are bathed by maternal blood and enter the circula- 
tion; therefore the ovum has a certain enzyme action, and the fetal 
cells may be said to furnish or represent a placental secretion. 

On the other hand, the blood contains elements which exert a 
corrosive action on the trophoblast cells, changing them to syncy- 
tium. The resulting syncytial cells then cover the villi ; they play 
the part of endothelium (which they then greatly resemble), and 
prevent the cells of Langhans and the stroma from further cor- 
rosive change by the blood. That the individual cells in chorio- 
epithelioma have the power to grow without limit, and that the 
cells entering the circulation have the energy to produce malignant 
metastases, shows that the decidua and the blood no longer have 
the power to limit and control their growth. 

Chorioepithelioma, occurring generally after abortion or hy- 
datid mole, is probably the cause, rather than the result, of the 
abortion. Chorioepithelioma represents a more advanced stage 
than that of hydatid mole, but both of these conditions, in a basic 
way, follow the normal processes in their course and growth. The 
only difference is the power of unlimited growth possessed by the 
chorionic cells in these pathologic conditions. The difference in 
the resistance offered by the patient points to a constitutional 
element, the lack of some normal secretion, as an important factor 
in the etiology of chorioepithelioma. 

It may be said that chorioepithelioma is due to the fact that re- 
sistance to the fetal enzymes and fetal cells offered by the blood 
and a secretion, probably the ovarian secretion, is insufficient to 
hold the growth of the fetal cells in check. Every case of hydatid 
mole should be followed and the possible development of chorio- 
epithelioma should be held in mind. If, after abortion or labor, 
the uterus does not return to normal size, if irregular or profuse 
bleedings develop, the existence of a chorioepithelioma should 
be considered as a possibility. The scrapings after curettage 
make the diagnosis. To the finger, introduced into the uterus, 
the feel is like that of a carcinoma. This condition may develop 
even two to three years after labor. 

Treatment of this condition consists of panhysterectomy. 

39 



FIBROMYOMATA 

Myomata or fibromata or fibromyomata of the uterus, commonly 
called fibroids, are tumors which arise and develop interstitially 
in the wall of the uterus and from their subsequent situation are 
known as submucous, interstitial, or subperitoneal. From what 
these tumors originate is not known. It is probable that they are 
due to cells displaced during the fetal development of the two ducts 
of Miiller into the genital tract and to failure of trophic control over 
the uterus by the ovaries. 

Fibromyomata are originally multiple, but only some of them 
develop. Generally one develops greatly, overtops the others, 
and is surrounded by smaller ones. Sometimes there is a group 
of fair-sized tumors. All fibromyomata are originally interstitial. 

Fibroids are present in many uteri, but never develop to any 
extent. We often see them developing in pregnancy and under- 
going involution later. These are pure myomata, composed of 
muscle tissue, which undergo the same involution changes as the 
uterine muscle does after labor. 

Fibroids may be very small or very large. They may enlarge 
the uterus so evenly that the resemblance to pregnancy is marked, 
or they may give it an irregular outline through multiple tumors 
extending into the general abdominal cavity or into the broad liga- 
ments or into the cul-de-sac of Douglas. 

They may be situated in the cervix or fundus. If situated 
sufficiently far down in the cervix, they may develop retroperi- 
toneally by pushing up the peritoneum which lines the cul-de-sac 
of Douglas. They may be broad-based or pedicled and their 
connection with the uterus may be lost by thinning and absorption 
of the pedicle. They move with the uterus, but if pedicled they 
move independently. If intraligamentous or subperitoneal they 
are less movable. Adhesions may limit their mobility or they may 
be firmly incarcerated in the pelvis. 

Myomata are round, but when stretched and changed by preg- 

610 



FIBROM YOM ATA 6 1 1 

nancy they become broader and flatter. They consist of connec- 
ive tissue and muscle. The more the connective tissue, the harder 
they are. A pure fibroma is very hard. A pure myoma is quite 
soft. Fibroids become harder through calcification or sclerosis of 
the connective tissue. They become softer in pregnancy or through 
fatty degeneration. They become soft and cystic or larger through 
gangrene, inflammatory changes, lymph- cyst changes, hemor- 
rhage, etc. 

Fibroids are by no means an obstacle to pregnancy, and their 
effect on the course of gestation depends upon their situation, on 
the amount of hemorrhage associated with them, and upon the 
manner of their growth, for by this latter change room for the 
growing ovum may be limited. A differential diagnosis between 
a fibroid uterus evenly enlarged and of no very firm consistence 
and pregnancy must often be made. 

Fibroids usually increase in size in pregnancy and often di- 
minish in size and disappear after labor, being then of the form 
called myoma rather than fibroma. The position of a fibroid or 
fibroids may interfere with or obstruct the progress of child- 
birth, but rarely does so absolutely. Conservative action often 
causes, even after many hours, a spontaneous change of posi- 
tion of the fibroid tumor, so that labor is ended normally. With 
absolute obstruction a laparotomy and Cesarean section are nec- 
essary. 

Fibroids supposedly shrink or cease their growth at the meno- 
pause age, because the congestive stimulation of the ovarian se- 
cretion ceases and a state of pelvic anemia results which fails to 
furnish the fibroids with proper nutrition. On the other hand, 
they may prolong menstruation for years beyond the menopause 
age. They often grow rapidly at this period instead of disap- 
pearing. The most dangerous changes occur at this time just 
because of the lack of sufficient blood-supply, and fibroids may 
increase rapidly in size. They may grow rapidly by actual in- 
crease of tissue or by degeneration of their structure accompanied 
by necrosis, hemorrhage, etc. A fibroid may degenerate in struc- 
ture in various areas, or it may even undergo purulent degeneration. 
Fibroids become readily infected by intrauterine examination, or 
if they extend through the cervix into the vagina where they come 



6l2 MEDICAL GYNECOLOGY 

in contact with vaginal bacteria. Fibroids may become separated 
from the uterus and be nourished parasitically by union with the 
omentum, tubes, ovaries, bladder, or intestines. Very large ves- 
sels run from these structures to the fibroid and supply it with 
blood. The twisting of this arteriovenous pedicle of blood-supply 
may cause ascites. Carcinomatous changes are very rare, but 
sarcomatous changes are stated, on good authority, to occur. 
Carcinomatous changes in a fibroid take place only when some 
of the epithelium which lines the uterine cavity is taken up into the 
structure of the fibroid by its growth, thus becoming separated 
from its parent endometrium. 

Symptoms. — The symptoms which fibromyomata produce are 
increase in size of the uterus, generally with enlargement of the 
uterine cavity; bleeding, especially in the submucous and some- 
times in the interstitial variety. They rarely produce pain, unless 
incarcerated beneath the promontory of the sacrum or unless the 
blood which is poured out coagulates quickly and is expelled from 
the uterus as large clots. Fibromata in their growth are surrounded 
by a zone rich in blood-vessels, for in fibroid itself the blood- 
supply is poor. Either this zone comes close to the surface of the 
uterine lining or else the mucosa over the fibroid is in a state of 
hyperplastic development, or else it is thinned out, or else the sur- 
face of the fibroid projects in broad-based or polypoid form into 
the cavity of the uterus. Under such circumstances bleeding, 
which is generally of the form of menorrhagia, may sometimes 
take the form of metrorrhagia. Hemorrhage is most marked in 
the submucous or polypoid form. In' fibroids situated intersti- 
tially, and especially subperitoneally, irregular bleeding is rarely a 
symptom. They evidence themselves then mainly through the 
increased size of the uterus and through the pressure- effects on the 
surrounding structures, such as intestine or rectum, bladder or 
ureters. 

In addition to hemorrhage, which may be of the form of men- 
orrhagia or metrorrhagia, there may be pain through weight and 
pressure of the fibroid; there may be dysmenorrhea due to the 
expulsion of large clots through the cervix or there are evidences 
of pressure on the bladder, ureters, rectum, or sacral nerves. In- 
carceration within the pelvis of uterine and especially of cervical 



FIBROMYOMATA 613 

fibroids may compress the bladder, causing great distention of 
that organ, with pain and constant dribbling of urine. 

Diagnosis. — An interstitial myoma or fibroma being situated in 
the wall of the uterus is covered with muscle fibers. The uterus 
is of hard consistence. The diagnosis from chronic metritis or 
fibrosis is difficult if the uterus is not large. In chronic metritis the 
uterus is evenly enlarged, the cervix and fundus are both thickened. 
If a sound is passed into the uterus and the uterus is palpated 
through the abdomen, by manipulation of the sound the even or 
uneven thickening of the uterine wall may be noted. The larger 
the uterus and the harder the uterus, the more probable is the 
existence of a fibromyoma. The uterus is then enlarged, the cavity 
is lengthened and widened. An interstitial myoma of the cervix 
gives an irregular knotty wall with an even enlargement of the 
uterus. The diagnosis from pregnancy in the early months is 
often difficult, especially from pregnancy with dead fetus. 

Subserous fibromyomata are not covered with much uterine 
tissue, but with peritoneum. They are broad-based or pedicled. 
They may be entirely separated from the uterus. They may grow 
intraligamentous and can be become separated from the uterus. 
If deep down in the uterus or if in the cervix, they may grow under 
the Douglas peritoneum, push it up, and are then retroperitoneal. 
A fibroid may, from such an origin, become intraligamentous. 
The diagnosis of subserous myomata is often difficult. We attempt 
to palpate the round ligaments over the tumor. A sound shows 
the uterus to be always enlarged, except with subserous pedicled 
tumors. With pedicled myomata the uterus preserves its form 
and we feel the knobs. With them a differential diagnosis from 
ovarian tumors is necessary. (See page 660.) 

Submucous fibroids, whether broad-based or pedicled, grow 
toward the uterine cavity and are covered with mucosa. If such a 
fibroid grows into the uterine cavity it dilates the uterus and the 
cavity is lengthened and widened. It stimulates the uterus to 
contraction, which may cause the fibroid to protrude from the 
cervix as a fibrous polyp. The submucous type causes much 
bleeding. The uterus is enlarged and round, the portio is felt to 
pass over into the enlarged uterus. A submucous fibroid often 
dilates the cervix and the lower uterine segment like a balloon. 



614 MEDICAL GYNECOLOGY 

A differential diagnosis must be made from pregnancy and from 
metritis. 

In the differential diagnosis of fibroid jrom pregnancy it must be 
remembered that in the latter there is amenorrhea, morning nausea, 
colostrum in the breasts. On bimanual examination the pregnant 
uterus undergoes in the course of a few minutes changes in con- 
sistence. Later on fetal movements can be felt and heard and the 
fetal heart can be heard. A still more difficult diagnosis is that of 
early pregnancy combined with fibroids. Amenorrhea is not 
always a symptom, for bleeding, which is often a symptom of fi- 
broid, may be present. The other symptoms of pregnancy and the 
softer condition of the uterus are points of importance. A fibroid 
uterus may stimulate the breasts to secretion of milk, so that this 
element is not of absolute importance in a differential diagnosis. 

With a living fetus the most important sign is the change of 
consistence which the uterus undergoes in the course of a few 
minutes under bimanual examination. The myomatous uterus 
is usually harder. In the later months the symptoms of preg- 
nancy and the evidences of fetal movements and the beating of 
the fetal heart make the diagnosis. 

Not infrequently a differential diagnosis must be made from 
retrouterine hematocele. The latter, however, becomes harder 
and harder after the blood has coagulated, and causes peripheral 
adhesions and is more closely connected with the pelvic walls. 
In differentiating an intraligamentous fibroid from intraligamen- 
tous hematoma it is to be noted that the latter shrinks gradually. 
With fibroid the uterus is enlarged, but in many cases the differ- 
ential diagnosis is difficult and can only be made after continued 
observation. A retrouterine fibroid must be distinguished from 
the retroflexed fundus by rectal examination and by the use of the 
sound. The cervix is dilated during menstruation, and if the 
finger is then passed into the cervix, a foreign body is felt in the 
case of a submucous fibroid. This must be differentiated from an 
ovum or the retained products of an abortion. It must be remem- 
bered that an ovum or any of its retained parts may be loosened 
from the wall of the uterus by the examining finger, whereas a 
fibroid cannot. A retained placenta may be so firmly adherent as 
to be diagnosed as a submucous fibroid until its removal makes 



FIBROM YOM AT A 6 1 5 

the diagnosis. Mucous polyps are to be diagnosed by the fact 
that they are oval, tabulated, and soft, and have a thin pedicle. 

Fibroids, unless they endanger the health of the patient by the 
amount of hemorrhage, by rapid growth, by their size, or by 
pressure or by degenerative changes, are not necessarily to be 
operated on. The fibroids which are subperitoneal with a base 
not too broad, as well as smaller interstitial fibroids, may be re- 
moved by myomectomy. Otherwise, if operation is necessary 
hysterectomy should be done. The former procedures of double 
ovariotomy or of tying off the vessels which supply the uterus with 
blood are no longer in vogue. 

Fibromata are generally recognized in the thirties of a woman's 
life. Organic myocardial or functional cardiac changes are noted 
in 30 to 40 per cent. Fibroids cause changes in the liver and 
kidneys through loss of blood, pressure-effects, and intoxication. 

Sequelae. — Boldt says: "The close relation between myomata 
and cardiac degeneration has been frequently alluded to in gyneco- 
logic literature for many years, but even the very latest text-books 
fail to give myomata a place as etiologic factors of cardiac degenera- 
tion. Yet the circulatory symptoms frequently observed in pa- 
tients having uterine fibroids suggest that there is some relation 
between these neoplasms and the circulatory apparatus, showing 
that these growths produce a detrimental effect on the circulatory 
system. Cardiac changes in women having fibromyomata occur 
too often for one to simply consider them as a mere coincidence." 
Of seventy-nine recent cases of fibromata, Boldt found in thirty- 
seven patients (nearly 47 per cent.) some circulatory disturbance. 
He finds five classes: 

Class 1. — Dyspnea on exertion, also a small, rapid pulse with 
arrhythmia. There is moderate hypertrophy of the right ventricle. 

Class 2. — Orthopnea and irregular and intermittent pulse; in- 
crease of dullness over the entire cardiac area; hepatic dullness 
slightly increased; albumin and casts in the urine. 

Class 3. — An arrhythmic, hard pulse, with occasional attacks of 
angina pectoris. In the urine there is a trace of albumin, and 
there are some granular and hyaline casts. 

Class 4. — A rapid pulse, from 100 to 126 beats a minute, which 
on sudden exertion increases from ten to twenty beats; the pulse 



6l6 MEDICAL GYNECOLOGY 

is small and easily compressible. The patients are easily fatigued 
on exertion. The urine is normal. 

Class 5. — Includes the largest number. There are no symptoms 
referable to the heart, but the pulse is small, of low tension, oc- 
casionally irregular, from 86 to 1 10 beats a minute. Pain on press- 
ure over the second sternointercostal space is noted in half the cases, 
associated with pain on pressure over the apex. There is a trace 
of albumin in the urine in some cases, associated with occasional 
granular and hyaline casts. There is no appreciable change in 
the heart area in any of these cases. 

" One must regard the degenerative condition of the heart muscle 
as being to a large extent, if not entirely, a cause of fatal termina- 
tion." 

Fleck states that "myofibrosis of the heart may also occur as 
the cardiac lesion in connection with myomata of the uterus; 
further, that the lesion in connection with myomata resembles 
that of myocarditis, without being exactly identical with it. Brown 
atrophy, however, is anatomically recognized as a lesion frequently 
associated with myomata." In his conclusion he maintains that 
myomatous uteri are frequently associated with an affected heart 
muscle, which can be caused only by the action of poisonous sub- 
stances. Myomata are invariably associated with gross anatomic 
changes of the ovaries, and from this source Fleck believes the 
poisonous products to originate. 

Leopold and Ehrenfreund, in three cases of death among their 
last fifty-one vaginal hysterectomies, found fatty degeneration of 
the muscle and numerous pulmonary emboli, also thrombosis of 
pelvic veins and those of the lower extremity. Fatty degeneration 
of the kidneys was also present in one of these cases and paren- 
chymatous nephritis in another. 

Boldt says: "That a relation exists between myofibromatous 
tumors and degenerative changes in the heart and other circulatory 
changes is sufficiently accepted by competent observers to cause us 
to consider these tumors dangerous to life from other causes than 
degenerative changes in the tumors themselves. In fact, the malig- 
nant changes in these tumors do not so frequently give rise to a 
serious aspect as do the degenerative changes in the circulatory 
system." 



FIBROM YOM AT A 6 1 7 

" Women who have sustained large losses of blood frequently 
show symptoms of anemia, manifesting itself in cardiac palpitations, 
dyspnea, edema of the lower extremities, and more or less al- 
buminuria. These symptoms often disappear on the cessation of 
the bleeding, but if the attacks of bleeding frequently repeat them- 
selves, such symptoms are likely to become permanent and leave 
their effect on the heart muscle. That such effect on the heart is 
not alone caused by menorrhagia and metrorrhagia is proved by 
the fact that degnerative changes in this organ are also seen in 
patients who have not suffered such large losses of blood as the 
result of the tumor (in Fleck's cases, brown atrophy was especially 
found in the patients who had no hemorrhage), and their absence 
in women who have sustained large losses of blood from other 
causes than myomata. There is no particular form of cardiac 
degeneration distinctly attributable to myomata, but we know that 
there are various pathologic conditions of the heart, blood-vessels, 
and kidneys frequently associated with myonbromatous tumors 
of the uterus, and that the effects which frequent and profuse 
hemorrhages produce, manifest themselves in fatty' degeneration 
and brown atrophy of the heart muscle. Clinical experience has 
taught us that patients with myomata have a weak heart, especially 
if the tumors have attained considerable size, and cardiac weakness 
may lead to venous thrombosis, especially in the pelvic and femoral 
veins, and then to pulmonary embolism. There can be no ques- 
tion that patients with fibroids of long standing have their resistance 
to anesthetics impaired, their pulse is frequent, small, and easily 
compressible, and sometimes irregular. They complain of inabil- 
ity to undergo physical exertion, tiring very soon, and often com- 
plain of cardiac palpitation. This lack of resistance frequently mani- 
fests itself only when an operation is undertaken for the removal of a 
tumor, because at that time the tax on the respective functions is at 
its height. If the heart affection is the primary condition and in- 
dependent of the myoma, then the removal of the tumor can have 
no effect upon it, and the progress of the cardiac affection is not in- 
terrupted by the extirpation of the neoplasm, but the fact that has 
been clinically proved, that removal of such tumors has produced a 
beneficent effect upon the heart, shows that there is a causal con- 
nection between the conditions. We know, of course, that some 



6l8 MEDICAL GYNECOLOGY 

patients may have heart lesions without complaining of any symp- 
toms referable to such lesions. Further evidence of a connection 
between myomata and the circulatory apparatus is found in the 
fact that arteriosclerosis of the ovarian vessels is frequently found, 
also in the pathologic changes in the constituent elements of the 
blood. Further, myomatous patients frequently begin to men- 
struate late, have profuse flow, and suffer from dysmenorrhea. 
The mechanical changes in the heart, like dilatation and hyper- 
trophy, have a position subordinate to the myocardial changes." 

"I have stated that cardiac degeneration favors renal changes, 
but, on the other hand, if a tumor presses on the ureters, renal 
degeneration may be produced, which, in its turn, may lead to 
cardiac degenerative changes. 

"The changes in the blood-vessels in the immediate vicinity of a 
myoma have an important bearing on the occurrence of emboli, 
the enlargement of the veins furthering the development of throm- 
bosis and embolism, both before and after an operation. 

"It is exceedingly difficult sometimes to diagnosticate cardiac 
changes clinically; they may be suspected if there are present 
respiratory disturbances without demonstrable pulmonary lesion. 

"While the size of tumors does not bear any positive relation to 
the degenerative changes in the heart muscle, we must admit that 
such changes are more likely to be present in tumors of large size, 
when they extend above the umbilicus, especially if hemorrhage 
has been a prominent symptom." 

Treatment. — "The practical deduction to be made is that per- 
sons who are the subjects of myomata should be especially well fed 
and take sufficient exercise during the intervals of bleeding and 
menstruation. They should eat plenty of meat, and have such 
diet and exercise as will have a tendency to reduce the adipose 
tissue, with which they are frequently abundantly supplied, and 
to increase the muscular tone. Further, that such patients should 
be advised to have the tumors removed ; cardiac and renal changes, 
unless hopelessly advanced, being an indication rather than a 
contraindication for their removal, because it also seems that 
patients who have myomata succumb more readily to cardiac in- 
sufficiency if attacked by an intercurrent disease. Treatment 
should be directed to the heart before an operation if myocarditis 



FIBROM YOM AT A 6 1 9 

symptoms are present. Intravenous infusion should be employed 
at the beginning of the operation if the hemoglobin is materially 
reduced. After the operation such patients should also receive 
heart treatment to act against the formation of thrombosis. 

"Advice for the removal of such tumors should also be given if 
it is ascertained that the neoplasm has a rapid growth, or if it 
causes much pain or other marked symptoms. I may add that 
in every instance in which I have had the adnexa (tube and ovaries) 
and the endometrium of myomatous patients examined, and there 
have been more than one hundred cases, changes have been 
found in these structures" (Boldt). 

For the treatment of the bleedings associated with fibromyomata, 
the reader is referred to the section on Uterine Bleedings. 



INFLAMMATION OF THE FALLOPIAN TUBES 
SALPINGITIS— SALPINGO-OOPHORITIS 

Salpingitis is an inflammation of part or all of the Fallopian 
tube. We distinguish three degrees of salpingitis: (i) A mild 
form, scarcely to be recognized, which involves the ciliated epithe- 
lium and to some extent the mucous membrane. (2) Involve- 
ment of the mucous membrane. (3) An interstitial form which 
involves also the muscular wall and which thickens the tube. The 
third form is generally associated with more or less adhesions, hav- 
ing a tendency to close the outer end of the tube. Cases beyond 
these grades are to be considered as hydrosalpinx or pyosalpinx. 
The same variations in the degrees of inflammation are to be noted 
in salpingitis as are observed in appendicitis. Restoration to the 
normal, or so nearly to the normal as to present almost no micro- 
scopic evidences, occurs in salpingitis as in appendicitis. Restora- 
tion to the normal in salpingitis, however, is a process which takes 
months or years, as can be readily appreciated when we consider 
the cocci which are so frequently present in this inflammation. 

Etiology. — The elements of infection may enter the tube through 
the blood-channel (tuberculosis), through the abdominal cavity 
(tuberculosis, septic parametritis, septic peritonitis, appendicitis), 
or in the form of an ascending infection from the cervix, either 
directly through the uterus into the tubes or through the lymphatics 
of the broad ligaments into the tubes. While it is true that far 
more frequently than is recognized the exanthemata produce 
permanent harmful changes in the uterus, and either primary or 
secondary changes in the uterus and tubes, yet the causation in 
the majority of cases of tubal disease is to be referred to the bac- 
teria generally found in the diseases of the urinary and genital 
tract. 

The bacteria most frequently encountered are the tubercle 
bacillus, colon bacillus, streptococcus, staphylococcus, and gono- 
coccus. Infection may occur in children, in nulliparae, or in multi- 

620 



INFLAMMATION OF THE FALLOPIAN TUBES 62 1 

paras. The seat of the primary infection is in most cases the 
cervix, or the cervix and uterus, extending then at various 
times and in various degrees of severity into one or both tubes, 
or first into one and then into the other, or into one tube and 
through the abdominal cavity into the other. The cause of salpin- 
gitis in nulliparous women may be infection without or with 
intrauterine manipulation. With intrauterine manipulation, in 
addition to infection, there may be an injury to the tube as a re- 
sult of intrauterine injections, which, not rarely, find their way 
into the tubal lumen. The cause of salpingitis in nulliparous 
women without intrauterine manipulations is in most cases a latent 
unrecognized gonorrhea existing in the form of an endometritis. 

It is first important to recognize the fact that an injury, even ex- 
tensive in its nature, may be present in one tube without an appar- 
ent involvement of the tube of the other side, or else there may be 
an involvement of the other side of much slighter degree, or an in- 
volvement which can scarcely be recognized. This association of 
widely divergent degrees of inflammation may be present even 
with a pyosalpinx. 

The etiology of salpingitis in adults, then, is as follows : 

1. The diseases of childhood and gonorrhea in childhood are 
responsible for some instances when other later sources of infection 
may be positively excluded. 

2. To unrecognized tuberculosis a certain number may be at- 
tributed. 

3. Others may be referred to infections of a mild type after labor 
or abortion or curetting. 

4. We must grant, however, to the gonococcus of saprophytic 
type the responsibility for causing the larger number. 

5. An interesting point is the frequency with which lesions of the 
right side are more pronounced than those of the left. An ex- 
planation can be found only in the presence of the appendix, and 
the associated evidences of appendicitis are rather proofs of the 
cause than evidences of a complication. If we grant to an appendi- 
citis, even if only catarrhal, the occurrence of some peritoneal 
irritation and exudation, it is only natural that the action of the 
tubal cilia would attract into the tubes, particularly on the right 
side, the infecting bacteria, generally the bacterium coli. That, 



622 MEDICAL GYNECOLOGY 

then, would explain the resulting mild adhesions, especially in in- 
stances of exclusively right- sided involvement. 

Histopathology. — The inflammation of the mucous lining 
claims our special attention. Involvement of the tubal wall and 
the serous covering is not uncommon. The mucous membrane 
may be secondarily affected, as is the case when the infectious pro- 
cess makes its way from the peritoneum inward. Through result- 
ing perisalpingitic strands there may occur torsions and displace- 
ments of the tube and ovary. The result of an inflammation of the 
mucous membrane is usually swelling of the folds, and hyperemia, 
which, if it occurs in the numerous blood-vessels of the abdominal 
ends of the tubes, causes serous exudation which leads to adhesions 
at the abdominal opening, and may result in complete closure. 
By the forcible stretching which the tube may undergo in the course 
of such-a closure, the entrance to the uterus is made so narrow that 
even in the absence of real atresia at this point the exit of fluid is 
impossible. 

Whatever may be the cause of such inflammation, the evidences 
are the same as in other organs. As a result of inflammation we find 
numerous round cells in the tissue, so that its normal elements are 
completely overwhelmed by the round cells. The result is a swell- 
ing of the folds in the tubal lining, which lie close together and 
easily become adherent. The epithelium of the surface is usually 
intact, but we see the round cells forcing their way through the 
epithelium at many points and lying in the canal, which is nar- 
rowed by the swelling. 

The process does not usually extend deeper. Now and then we 
see strands of round cells following the vessels in the muscularis. 
As a rule, hyperemia affects the serous covering, and the peri- 
toneum looks very red and swollen, and shows numerous signs of 
inflammation, leading to the formation of fine membranes. In 
this way long-standing inflammations lead to adhesion of the tubes 
to neighboring organs. 

Diagnosis. — These milder forms of salpingitis are classified as 
salpingitis, oophoritis, perioophoritis, salpingo-oophoritis, etc. 
The lesions of importance are the slight localized peritonitis, the 
oophoritis, and the varicose condition of the broad ligaments. It 
is these which give the patients the annoying symptoms; it is be- 



INFLAMMATION OF THE FALLOPIAN TUBES 623 

cause of these that interference is warranted. We do not refer 
here to large pus tubes, to large tubo-ovarian tumors; but to lesions 
which the examining fingers scarcely make out as tangible ones. 
The patients complain of pain and are primarily or secondarily 
sterile. Examination is generally productive of pain and often 
divulges the presence of a prolapsed ovary more or less fixed. To 
this class of patients belong the large number in whom no other 
than a tubal or peritoneal cause explains sterility, if examination 
and treatment prove all other requirements to be fulfilled. It is 
in this class, too, that operation, primarily for sterility, is justified. 
We find adhesions, thin cobweb adhesions, closing the outer end of 
the tube, fastening the ovary in the sac of Douglas, and preventing 
the entrance of an ovum into the tube. The ovaries are often of 
the type of small cystic degeneration. Strange to say, the degree 
of pain is not always in proportion to the amount or character of 
the adhesions, as peritoneal sensitiveness is a most varying quality 
and least pain is often experienced where most warranted by local 
changes. (See Ovarian Dysmenorrhea.) 

Sequelae of Mild Salpingitis. — The two important sequelae 
of salpingitis are sterility and ectopic gestation. If both tubes are 
closed at their outer ends sterility is absolute. However, many 
cases of salpingitis are present without closure of the outer end. 
There is an involvement of the mucosa of the tubes, a hyperemia 
and a swelling of the folds, and very frequently a paraoophoritis, 
complicated by a varicose condition of the veins of the broad 
ligament situated near the ovary, which in these cases is due to 
parametritis. If the involvement of the mucosa interferes with 
or destroys the action of the ciliated epithelium an ovum cannot 
enter the tube and sterility takes place. There may exist, then, 
cases of salpingitis without pain so long as there is no peritoneal 
or ovarian involvement. These are the cases which may go on to 
healing and in which subsequent pregnancy may take place. At 
the same time these are the very cases in which ectopic gestation 
may occur. 

Abel, in his "Gynecological Pathology," attributes to affec- 
tions of the mucous membrane the etiology of many cases of ec-' 
topic gestation. 

My own views as to the causation were as follows : I believe that 



624 MEDICAL GYNECOLOGY 

in the so-called sterile period gonorrheal, puerperal, tubercular, 
and atrophic changes take place. The interval of years between 
the last labor and the ectopic gestation, the fact that the location 
is generally in the middle area of the tube, the occurrence of an 
ectopic gestation on both sides at the same time, and the frequency 
of external migration, together with the combination of extrauterine 
and intrauterine gestation, point certainly to an affection of one tube, 
and to involvement of lesser or greater degree of the other tube. 
The frequency with which, according to Kiistner, a hemorrhagic 
tendency of the non-pregnant side occurs, as well as the micro- 
scopic discovery of catarrhal conditions, together with the history 
and the microscopic evidences of the presence of gonococci, 
point distinctly to a tubal affection. The observation of Duhrssen, 
who found cilia abdominal to the placental site and none median to 
it, and Veit's observation of the presence of inflammation median 
to the ovum, as well as the theory of congenital and acquired 
atrophy of the tube, especially subsequent to labor, lead us at the 
present day to seek in the microscopic changes of the tubal mucosa, 
i. e., injury to the cilia, the etiologic factor in tubal gestation. Sub- 
sequent observation has still more surely confirmed my opinion. 

The purpose of quoting these observations on ectopic gestation 
is this : There is certainly some obstruction in the tube which pre- 
vents the ovum from entering the uterus. This obstruction is 
either an inactivity on the part of the ciliated epithelium as a 
result of inflammation, or else edema and adhesions of the tubal 
mucosa. The ovum is arrested in its progress toward the uterus. 
Such a tube, whether in an early stage of inflammation and slightly 
involved, or in a late stage and nearly healed, must certainly be 
fairly normal in its outer end to permit the ovum to be taken up into 
the tube at all, and yet, to the eye at least, these tubes do not ap- 
pear markedly affected. As further poof, we find, in many of 
these cases, the other tube affected to an extent which warrants its 
removal. In my hands, ten non-pregnant closed tubes were also 
removed at operation (28 per cent.). This simply represents the 
same variation in the degree of severity of the affection of the 
two tubes as is observed in most cases of salpingitis and even of 
pyosalpinx. 

Most cases occur in multiparas, yet a certain proportion do occur 



INFLAMMATION OF THE FALLOPIAN TUBES 625 

in nulliparae. I consider uterine or ectopic gestation, after long 
periods of non-artificial sterility and after conservative operations 
for inflammatory conditions, in most cases an evidence that restor- 
ation to the normal has taken place in the tubes in whole or in 
part. I consider ectopic gestation as an evidence that either a 
tube is beginning to be affected at the tubal end or that it is almost 
restored to the normal at the abdominal end. 



HYDROSALPINX 

Hydrosalpinx is a cystic, elongated tumor situated lateral or 
posterolateral to the uterus, and which on bimanual examination 
becomes gradually smaller as the uterine horn is approached. Ad- 
hesions of various parts of an inflamed tube with each other have 
been formed, with twistings and turnings of the tubal canal in long- 
continued cases. As a result of the primary catarrhal inflammation 
there is a firm closing of the abdominal opening, because the swell- 
ing pushes the fimbriae close to each other, causing finally a mutual 
adhesion. Then begins the chronic stage, for the tube, closed at 
both ends, gives no outlet to the secretion resulting from the inflam- 
mation, which may constantly collect in the tube and which may 
grow to very large size. First the mucous membrane and then the 
muscle becomes atrophic from the pressure of the increasing fluid, 
and it is on account of the presence of numerous elastic fibers in 
the tubal wall that such swellings can exist for a certain period 
without bursting. At times it happens that such tubal tumors 
filled with serous fluid, when they reach a decided size, empty 
through the uterus, only to fill again in a short time. Landau, 
following the etiology of the conditions observed in the kidneys, 
has named this condition intermittent hydrosalpinx. The fact 
that the contents are always serous is characteristic of this process, 
but rupture of vessels occasionally occurs and the serous contents 
are mixed with blood. Another characteristic of hydrosalpinx is 
that in a short time the entire tube may become affected, so that 
we are dealing with a large cyst, which may be fully emptied by 
puncture or incision at one point. Hydrosalpinx is usually one- 
sided, but bilateral affections are not rare. 



40 



626 MEDICAL GYNECOLOGY 

TUBO-OVARIAN CYSTS 

When the ovary is involved with a hydrosalpinx and the two are 
united by adhesions, there not infrequently occurs a communica- 
tion between the tubal tumor and one or more cystic spaces in the 
ovary. This is the so-called tubo-ovarian cyst. In other cases 
there is no communication between the tube and the ovary, but the 
ovary is very much enlarged and consists of one or more large 
spaces resulting from inflammation of the follicles. Such tubo- 
ovarian cysts are situated either posterior to the broad ligament 
or on the floor of the pelvis or far over to the lateral wall of the pel- 
vis, or they may extend upward into the abdominal cavity. They 
have a more or less tense cystic feel and the diagnosis can be made 
if the dilated tube can be traced up to the uterine horn. How- 
ever, when situated posterior to the broad ligament its connection 
with the latter is often so intimate as to simulate an intraligamentous 
cyst. A differential diagnosis from ovarian cyst bound down by 
adhesions is often very difficult. The mobility of these tumors 
depends on their adhesion. When fixed to the floor of the pelvis 
they are not very movable. At times, however, especially when 
attached mainly to the sigmoid, they may be pushed up into the 
abdominal cavity as far as the mobility of the sigmoid will permit. 



PYOSALPINX 

Etiology. — It is not so long ago since the vast majority of cases 
of pyosalpinx were referred to sepsis (streptococci or staphylococci) 
after labor or after abortion or curetting. Though pyosalpinx 
certainly may be caused by other bacteria, and though at least 
2 per cent, of the cases are due to the bacillus tuberculosis, it is 
now quite generally recognized that the majority of these cases 
are due to gonorrheal infection, and yet, in innumerable instances, 
the gonococci cannot be found. They die easily, are destroyed by 
their own toxins, especially if in association with other bacteria. 
It is recognized that the gonococci in pyosalpinx either lose their 
virulence or disappear after a certain period of time. Yet they 
have been found in the tube wall when not present in the purulent 
accumulation. In puerperal cases gonococci are often found in the 



INFLAMMATION OF THE FALLOPIAN TUBES 627 

lochia, when not found before, and readily disappear, so far as 
examination by the microscope is concerned. The fact that they 
are not to be found is no proof of their absence. 

In one hundred and seventy-nine cases of puerperal endometritis 
Kronig found gonococci in the lochia of fifty. According to Kronig, 
examination of puerperal endometritis shows the relative propor- 
tions of the various infecting bacteria to be 2 per cent, staphylo- 
cocci, 27 per cent, saprophytes, 27 per cent, gonococci, and 43 per 
cent, streptococci. Most of the fatal cases are due to streptococci. 
The sequelae, then, of puerperal inflammations can be easily under- 
stood. 

When gonorrhea, originally acute, exists in nulliparae, and is 
continued on into pregnancy, it is then that abortion, labor, or 
curettage may produce a new development which is acute in all 
of its manifestations, leading on to purulent accumulations in the 
tubes, peritoneum, or pelvic connective tissue. On the other hand 
these local acute conditions may be cured to all intents and pur- 
poses, and months or years afterward an extension upward may 
take place, which extension is not necessarily acute in its character. 
The bacteria may have lost their virulence, the patient's tissues 
have grown somewhat accustomed to the cocci, have become more 
or less immune, and any new involvement may take on the charac- 
ter and nature of a subacute inflammation. Even in puerperal 
women free of fever a certain, though small, percentage show in the 
lochia, streptococci, staphylococci, gonococci, and bacteria. 

Histopathology. — There is a greater tendency for purulent 
inflammation to become chronic than to heal completely. Marked 
anatomic changes are found in cases which have come to operation 
after existing many years. The cause of a purulent inflammation 
is exclusively bacterial infection. The septic and gonorrheal forms 
are the most frequent. In comparison with these, infections due 
to other bacteria are relatively rare; among them may be con- 
sidered the pneumococcus (Frankel) and the bacterium coli. 
Septic inflammations are mostly puerperal, yet they may occur 
through infection during operations upon the uterus, or through 
propagation of a bacterial affection of the abdominal cavity, such 
as perityphlitis, etc. At times in gonorrheal affections a mixed 
infection may occur. The formation of pus occurs early, so that 



628 MEDICAL GYNECOLOGY 

the tubal contents consist of purulent secretion. On account of 
the numerous cells which this pus contains we usually are dealing 
with a thick, tenacious, and sometimes cheesy substance. In 
acute cases it is possible to distinguish the two main forms of in- 
flammation by finding either gonococci or streptococci. 

In purulent inflammation there is a marked infiltration of the 
mucous membrane with round cells and coexisting hyperemia of 
the vessels. The folds swell and become adherent or are united 
by the pus found between them. The cilia of the epithelia dis- 
appear, but I should like to call attention to the fact that, in spite 
of long-continued suppuration, the epithelium of the tubal fining 
is usually preserved, even on the surface, which is certainly in 
contact with the pus, and we find only here and there certain areas 
denuded of epithelium (Carl Abel). 

If the acute stage has gone into a chronic one, the adhesions 
and unions of the folds become constantly firmer and furnish re- 
markable pictures, for sections of epithelial spaces result which 
look like glands. These pictures are naturally the more com- 
plicated and the more difficult to judge the larger the number of 
folds originally present, especially in the ampullar end. 

In careful examination of such a specimen it may be found 
that the gland-like formations are always on the surface of the 
mucous membrane and never penetrate into the niuscularis. 

Chronic purulent inflammations cause entirely different condi- 
tions from the catarrhal form, for in the latter a large tube sac may 
be formed after a time in which the entire tube is uniformly affected; 
in the former this is not the rule. In purulent inflammation the 
tube is divided into different abscess cavities by adhesions of the 
various parts, so that in longitudinal section through the whole 
tube we see several cavities of different sizes completely separated 
from each other. 

This is the reason why such a chronic purulent salpingitis can- 
not be healed by simple puncture or incision. This could only be 
accomplished if a single tube abscess were present, such as happens 
occasionally. 

The stroma of the mucous membrane consists partly of round 
cells and partly of granulation tissue, and the vessels are increased. 
In the narrow spaces between the folds pus is seen, which consists 



INFLAMMATION OF THE FALLOPIAN TUBES 629 

of closely gathered round cells, bacteria, and of ten also red blood- 
cells. We are dealing, therefore, with a productive inflammation. 

With the exception of cilia, the epithelium remains intact in the 
chronic form for an astonishingly long time, and in the deeper 
folds even the cilia are not infrequently preserved. At times cases 
are observed in which large areas of the surface are robbed of 
their epithelium, for which process it is hard to find a plausible 
reason. 

This happens either through mechanical pressure exerted by the 
accumulation of pus or through direct purulent degeneration of 
the tissue. 

The tubal wall in chronic inflammation is almost always affected. 
In most cases there is hypertrophy of the wall, and we see the 
round-celled infiltration filling the interstices of the muscularis and 
also see large circumscribed groups of round cells which resemble 
lymphomata. The vessels, even up to the peritoneum, are often 
seen in sections surrounded by a thick circle of round cells. 

The folds may disappear, and through purulent destruction of 
the wall the latter becomes decidedly thinned, and perhaps before 
this the existing septa between the individual sections of the tube 
are destroyed and there results a genuine tubal abscess after the 
abdominal and uterine ostia are closed. 

The second result of a chronic inflammation is the formation of 
new connective tissue. In such a case the wall always becomes 
thicker and shows a firm consistence as the result of the connective 
tissue. The folds become atrophic, the mucous membrane has a 
stroma of firm connective tissue, the epithelium may disappear, 
and there may even result the firm closure of the tubal canal. Such 
a tube, even if thicker than a thumb, if no new injuries through ad- 
hesion with the abdominal organs take place, may cause the patient 
no annoyance (Abel). 

Ovarian Abscess. — If after chronic purulent salpingitis a tubal 
abscess results, the pus may break through into the ovary and 
cause a coexisting ovarian abscess. Even though no complete 
abscess is present, but only isolated pus formations in the various 
parts of the tube, the union of both organs may lead to the pene- 
tration of pus into the ovary and the formation of an abscess. 
Gradually then one large abscess develops. It may happen that 



630 MEDICAL GYNECOLOGY 

the tube goes directly into a corpus luteum and then a corpus luteum 
abscess may be formed. 

Symptoms. — Acute pyosalpingitis is either septic or gonorrheal. 
It is a condition which is not limited to the tube alone, but through 
the discharge of the inflammatory products into the peritoneum is 
associated with various degrees of peritonitis characterized by pain, 
sensitiveness, tenderness, abdominal distention, and temperature. 
Associated with this pyosalpingitis and peritonitis there may be 
involvement of the pelvic connective tissue, which is usually 
noted in the post-partum septic form. The gonorrheal form 
goes over into a subacute stage much more rapidly than the septic 
form. 

In chronic pyosalpinx there is involvement of the peritoneum 
with adhesions to various of the pelvic organs. There may be 
anomalies of menstruation. Menstruation occurs early, is profuse, 
and is associated with pain. These changes are due to the in- 
volvement of the uterine lining, to involvement of the uterine wall, 
involvement of the vessels about the uterus. The pain is due to 
adhesions and is increased at menstruation. Acquired dysmenor- 
rhea is a most important characteristic of such inflammations and 
is due to the changes occurring in the uterine lining and wall and 
in the ovaries. 

Diagnosis. — The diagnosis is made by bimanual examination. 
The normal tube can be felt only in patients with thin abdominal 
walls. The milder degrees of salpingitis can be made out with 
difficulty. In the milder degrees of salpingitis the ovary can be 
made out and is often more or less fixed by slight adhesions. If 
fixed to the lateral pelvic wall, it often escapes detection by the 
examining fingers. The more infiltrated and thickened tubes, 
up to the varying degrees of large pyosalpinx, can be made out 
more readily. In pyosalpinx and tubo-ovarian tumors the ovary, 
as a rule, cannot be distinguished from the tube. Adhesion of the 
tube and ovary to the posterior wall of the broad ligament is most 
usual. Examination generally shows tube and ovary in pyosal- 
pinx postero-lateral to the uterus, but they are often adherent in the 
cul-de-sac of Douglas. Tubo-ovarian cysts are generally situated 
posterior to the broad ligament, but more laterally than pyosalpinx. 
Tubo-ovarian cysts are often situated far over to the lateral wall of 



INFLAMMATION OF THE FALLOPIAN TUBES 63I 

the pelvis. When on the left side, adhesions to the sigmoid may 
be very marked. 

Pyosalpinx must be diagnosed from ectopic gestation. In the 
latter at least one menstrual period was passed ; there is irregular 
spotting or bleeding, there is often severe colicky pain. The 
uterus is generally, but not always, enlarged and is somewhat 
softer; there is pulsation in the uterine arteries. These conditions, 
however, may be present with involvement of the tubes, especially 
in the early stages. Gonococci and evidences of gonorrhea 
should then be looked for. 

In early salpingitis the uterus may be enlarged, through inflam- 
mation, there may be irregularities of menstruation, there is usually 
pulsation in the uterine vessels and a sausage-shaped tumor is 
felt, all of which renders the differential diagnosis from ectopic 
gestation difficult. Salpingitis is frequently double-sided and there 
is a leukocytosis. Temperature is present with acute salpingitis, 
but this is often noted with ectopic gestation associated with internal 
bleeding and absorption of the fibrin elements of the blood. Rectal 
examination is of great aid in determining the feel and character of 
the tube. As a rule, however, a pregnant tube is the softer. Gono- 
cocci and evidences of vulvar and cervical gonorrhea should be 
looked for. 

In distinguishing pyosalpinx from a small myoma the history is 
of greatest importance. Either a history of post-partum infection 
is present or else corroborative evidences of a gonorrheal infection 
are to be looked for. 

Differential diagnosis sometimes has to be made between pyo- 
salpinx and hematocele. It must be stated that in the latter the 
tube and ovary, as a rule, are situated in front and to the side of the 
mass which fills up the cul-de-sac of Douglas. 



TUBERCULAR SALPINGITIS 

Tuberculosis of the tubes is a frequent condition. It is usually 
a secondary change due to the presence of the bacilli in the peri- 
toneal cavity which are taken up by the ciliated epithelium of the 
tubes, and, therefore, affect the tubal mucosa. Many cases pre- 
sent the picture of catarrhal salpingitis and the diagnosis is only 



632 MEDICAL GYNECOLOGY 

established by examination of sections. It is probably often pres- 
ent in early or even advanced cases of tubal involvement, even 
when macroscopic examination shows no alteration of tuberculous 
nature. A change considered typical of tuberculosis is a small or 
multiple nodular thickening of the tube, the so-called salpingitis 
isthmica nodosa. The tube is firm and hard. In more advanced 
cases the tube ends are closed by adhesions and the tube is enlarged 
and contains a creamy purulent or cheesy material and tubercles. 
In still more advanced cases the tube gives the picture of a pyosal- 
pinx. There is often in the major forms, involvements of the 
peritoneum and ovaries with adhesions and ovarian abscess. 
When the tubes and uterus are studded with miliary tubercles or 
when a tuberculous peritonitis is present, the diagnosis is readily 
made at operation. 

On bimanual examination the condition found is either that of 
salpingitis or of pyosalpinx. When tuberculous peritonitis exists 
with ascites, and if temperature and tuberculosis of the lungs are 
noted, a probable diagnosis may be made. In cases without 
temperature the injection of tuberculin with a resulting tempera- 
ture reaction speaks for the specific tubercular nature of the tubal 
involvement, but this reaction may be caused by a tubercular 
focus elsewhere. 

Unless a rapidly growing thin-walled pus sac, or an ovarian 
abscess or a purulent exudate in the sac of Douglas renders vaginal 
incision and drainage necessary, the acute cases are treated as 
described under Perimetritis (pp. 521, 522, 523) and under Gonor- 
rheal Involvement of the Tubes, Ovaries, and Peritoneum (pp. 407, 
408, 409). After the acute stage, if pyosalpinx results, treatment 
for several months, but without intrauterine manipulations, as 
given under Chronic Metritis (pp. 507, 508, 509), should be carried 
out. Then the bacteria or cocci in the tubes either disappear or 
lose their virulence and operation, if necessary because of pain, 
is of little danger and post-operative stump-exudates (recrudes- 
cences of the associated cellulitis of the broad ligaments) are 
avoided. Tuberculous pyosalpinx, contrary to usual opinion, in- 
jures the general health of the patients the least of all tuberculous 
involvements (Geo. Gray Ward). After operation they improve 
remarkably. If hydrosalpinx or tubo-ovarian cysts cause pain, 



INFLAMMATION OF THE FALLOPIAN TUBES 633 

operation is indicated. The mild forms of salpingitis and the cases 
of salpingitis diagnosed by exclusion as the cause of sterility 
and salpingitis of the non-pregnant tube in ectopic gestation 
demand the treatment given under Chronic Metritis (pp. 507, 508, 
509), but without any intrauterine manipulation of any sort. With 
such cases, and with cases in which operation is performed to 
remove the adnexa of one side only, curettage should never be done.- 
It makes the unrecognized salpingitis of the other side worse, or 
starts it up if not present, it sends infection out into the broad liga- 
ments, causes varicocele of the broad ligaments and ovarian dys- 
menorrhea. It does this with a minimum of early annoyance, but 
with a maximum of eventual harm. After operation on the adnexa 
of one side, the patient should stay in bed for four weeks to diminish 
the tendency to extrusion to the other side. 



ECTOPIC GESTATION 

Etiology. — In former years our views concerning the origin of 
ectopic gestation depended mainly on the discovery of pathologic 
conditions macroscopically evident. Cases were reported with 
fibroma of the isthmus tubae or with polyps at the uterine end of 
the tube. The growth of the ovum in a tubal diverticulum or in an 
accessory tube was considered to furnish a satisfactory explanation. 
In some cases the pressure of ovarian or abdominal tumors was 
supposed to obstruct the onward movement of the ovum. Abel 
and Freund found in a twisting of the tube and in a failure of 
development a satisfactory theory for the frequent occurrence of 
ectopic gestation. Since, in a majority of the cases, peritoneal 
adhesions are present, these were and even yet are considered to 
so alter the course of the tube's lumen as to prevent the entrance of 
the ovum into the uterus. Therefore, visible inflammations were 
considered to be an important etiologic element. 

The experiments of Leopold have shown that the ovum given off 
by one ovary may enter the tube of the other side. The cases are 
not so rare in which the tube of one side was closed or absent, and 
although the corpus luteum verum was found in the ovary of 
the same side, yet an ovum had entered the uterus. Schroder, 
Koblanck, and others have found a pregnancy in a rudimentary 
horn between which and the uterus no epithelial connection existed. 
Many years ago Manierre collected thirty-nine cases of preg- 
nancy in rudimentary horns. The same is true of those cases 
in which the corpus luteum verum is on one side and the ovum 
has developed in the horn of a uterus unicornis of the opposite 
side. Kiistner removed a right-sided extrauterine gestation tube 
and a left-sided ovarian cyst. Shortly afterward a uterine preg- 
nancy took place. 

Such an external migration occurs frequently in tubal gestation; 
although Kiistner took note of the frequency of this event in only the 
last twenty-five of a series of one hundred cases, it proved to have 

634 



ECTOPIC GESTATION 63 5 

taken place in seven. Prochownik found that external migration 
had taken place in one case of eight which he had examined closely. 
Martin found the corpus luteum on the same side as the tubal 
gestation in thirty- seven cases, on the opposite side in four, and 
uncertain in thirty-six. 

External migration of the ovum has been viewed by Sippel and 
others as the etiologic factor in ectopic gestation. They believe 
that the ovum after its migration becomes too large to permit of its 
passage through the tube lumen. The examinations of Peters, 
and especially of v. Spee, however, show conclusively that no chori- 
onic villi are present until the ovum has been nourished for a con- 
siderable time by the decidua in which it is embedded. In addition, 
the Graafian follicle is in the majority of instances found in the 
ovary of the affected side, so that such an etiology would explain 
only the smaller number of cases. 

This migration, however, calls our attention to the presence of a 
pathologic condition in the mucous membrane of the opposite 
non-pregnant tube. While it calls our attention to the fact that 
the non-pregnant tube is often affected, it only proves that it is 
more affected than the tube in which the ovum is finally embedded, 
for some cilia must be present in the latter to influence the external 
migration of the ovum. Various experiments make it seem prob- 
able that in the perfectly normal tube no ovum can develop. 

In considering the history of those cases which have been closely 
noted it is found that ectopic gestation occurs most frequently in 
multiparas and that a sterile period of varying length precedes this 
pathologic development. Martin found that sixty-five multi- 
paras were affected as compared with twenty nulliparae. In a series 
of one hundred cases of Kiistner's only ten ectopic gestations oc- 
curred in nulliparae; the other eighty-seven had borne children 
and three had aborted. In twenty-four cases it occurred five or 
more years after the last labor; in fifty- five cases, from one to five 
years; and in eight, in less than twelve months. Veit found that 
in fifty-two cases of repeated ectopic gestation a sterile period of 
two to eleven years preceded the first ectopic gestation. Between 
the two events was a period of six weeks to six years. The primary 
sterile period represents the time in which inflammatory changes 
in the mucosa may occur, either gonorrheal, septic, or tuberculous. 



636 MEDICAL GYNECOLOGY 

These changes naturally involve the uterine end of the tube more 
than the abdominal, and in the subsequent course of events, when 
healing does result the uterine end improves slowly. 

Franz makes inflammatory changes in the tubes responsible for 
the occurrence of ectopic gestation. This is the more probable 
since inflammatory processes are so frequently found in the other 
tube. Franz found such changes in 80 per cent, of those cases in 
which a sterile period of two to seventeen years was noted. In 
cases where a sterile period of less than two years was observed, 
tubal changes of the other side were present in only 53 per cent. 
He comes to the conclusion that we must seek the etiology in those 
affections of the tubes which have run their course, and which, 
having for a long time prevented the moving of the ovum, have 
permitted a gradual and partial restoration to normal conditions. 

While in a certain number of cases no pathologic microscopic 
changes are found in the tubal mucosa, it may be explained by the 
fact that so-called catarrhal conditions frequently show little mi- 
croscopic change. Even during or after gonorrhea the tube may 
seem, macroscopically, fairly normal. Ahlfeld, in an experience of 
many years at the University of Marburg, met with so few cases of 
tubal gestation that he considers the relative freedom of his patients 
from gonorrhea, as compared with those in the larger cities, to 
be the only explanation. 

Various inflammatory influences are etiologic factors in that 
they destroy the cilia in whole or in part, or diminish their func- 
tional activity. 

Naturally, there must be activity to a certain extent on the 
part of the cilia at the abdominal end of the tubes, or the ovum 
would not be drawn into the tube at all. The fecundated ovum 
is drawn up into the tube, is carried along to a point where the 
cilia no longer functionate, stops there and an ectopic gestation 
has begun. 

Recurrences of tubal gestation take place but rarely in the same 
tube. Patellani, in a tabulation of thirty-six cases, found that 
first one tube and then the other was the seat of ectopic develop- 
ment. Veit, among fifty-two reported cases, found that it recurred 
only three times on the same side. An additional point of impor- 
tance is the occurrence of tubal gestation in either tube at the same 



ECTOPIC GESTATION 637 

time, of which Gebhard mentions nine cases. Further, Patellani 
has collected thirty-seven instances of combined uterine and extra- 
uterine gestation — a practical proof of an affection of one tube, 
and certainly excluding external migration as the cause. 

I believe that in the so-called sterile period gonorrheal, puerperal, 
or tuberculous changes take place. The interval of years between 
the last labor and the ectopic gestation, the fact that the location 
is generally in the middle area of the tube, the fact that repeated 
ectopic gestations are observed, the occurrence of an ectopic gesta- 
tion on both sides at the same time, and the frequency of external 
migration, together with the combination of extrauterine and intra- 
uterine gestation, point certainly to an affection of one tube, and 
an affection of different degree of the other tube. The frequency 
with which marked inflammation of the non-pregnant tube is 
noted, as well as the microscopic discovery of catarrhal conditions, 
together with the history and the microscopic evidences of the 
presence of gonococci in many cases, point distinctly to a tubal 
affection. The observation of Duhrssen, who found cilia abdom- 
inal to the placental site and none median to it, and Veit's observa- 
tion of the presence of inflammation median to the ovum, lead us 
at the present day to seek in the microscopic changes of the tubal 
mucosa, i. e., injury to the cilia, the etiologic factor in tubal 
gestation. 

The tendency is increasing to consider inflammatory changes 
as the cause of ectopic gestation. Some, however, say that the 
ovum has in some instances a well developed outer cell growth when 
it enters the tube, and that this causes its settling in the tube. 
Others consider a perisalpingitis subsequent to appendicitis as the 
responsible factor. Many claim that the cause is not known. 

Philander Harris agrees with my view. ' ' All who are experienced 
in suprapubic sections for pelvic disease will surely agree in the 
assertion that a very considerable percentage of women who have 
tubal pregnancy are found, when operated on, to have diseased 
tubes. Thus it must be apparent that in a certain percentage of the 
cases of ectopic gestation there are two symptoms producing factors, 
namely, salpingitis and pregnancy within a tube. Not very gross 
pathologic changes, coming from salpingitis, constitute the chief 
if not the only cause of ectopic gestation." 



638 MEDICAL GYNECOLOGY 

"It is the existence of salpingitis, the great sterilizing disease of 
women, which accounts for the fact that periods of sterility, vary- 
ing from three to fifteen years or more, so commonly precede the 
occurrence of tubal gestation. A previous attack of salpingitis 
not only causes the sterility, but also renders the tube incapable of 
conveying the fecundated ovum to the uterus." 

Histopathology. — The lining of the tube is composed of folds 
of mucosa. An ovum may begin its development situated on the 
surface of the mucosa folds, forming the columnar type of tubal 
gestation. An ovum may begin its development down deep among 
the folds of mucosa, forming the inter columnar type. An ovum 
may settle on the tubal wall and sink deeply into the wall of 
the tube. Its chief placental growth at this point results in 
penetration of the wall by villi. This is the centrifugal type of 
development. 

In the columnar type of development the ovum is surrounded by 
mucosa folds only. Such a columnar situation makes abortion 
easy and of little danger. Very soon after the entrance of the ovum 
tubal bleeding may result ; the ovum dies and further hemorrhage 
expels it. The tube may return to a normal state, without any 
evidences of the previous condition, or else a hematosalpinx may 
be formed if the abdominal end of the tube is closed. The ovum 
may, theoretically, develop to a much further degree and press the 
folds against the tubal wall. If development continues, the villi 
may extend into it, but the connection of the ovum and the villi 
with the surrounding tissue is a loose one. 

In the inter columnar form the ovum may rest on the wall of the 
tube. Any tubal fold beneath it will be compressed, but epi- 
thelium may be present in a depression. Other folds may form a 
capsularis or reflexa. The villi at the placental site enter into the 
wall ; here a hemorrhage may result, through this invasion of the 
wall and of the vessels, and through the invasion of the capsularis 
by fetal cells; or the capsularis may rupture. If it be torn, or if 
it be not closely adherent, the intervillous space is opened. Abor- 
tion, complete or incomplete, usually incomplete, is the general 
rule, but rupture might occur. If the abdominal end be closed, a 
hematosalpinx or a tubal mole may represent the final outcome. 

In the centrifugal form the ovum sinks into the wall of the tube 



ECTOPIC GESTATION 639 

and an invasion of the wall and vessels by the villi may take place, 
even up to the serosa. The capsularis is formed by muscularis 
and mucosa. It may rupture at its summit. The villi which ex- 
tend up to the serosa may cause bleeding, though their penetration 
is so gradual that these points are usually covered by thrombi. 
Finally a rupture may take place at the placental site through 
perforations, producing an arrosion. The ovum practically eats 
up the wall. Even though the tubal diameter be large enough to 
give sufficient room, this occurs. It is not the result of pressure, 
as may be seen in gestation at the fimbrian end, where rupture also 
can result. Villi which perforate the serosa may cause a very 
decided hemorrhage into the peritoneal cavity. When no rupture 
has occurred and the abdominal end of the tube is closed, only the 
microscope may divulge the source of such an intraperitoneal 
bleeding. Such minute perforations may cause collapse through 
hemorrhage, even though the opening be no larger than the head 
of a pin. Even after the death of the ovum the villi can grow, and 
an active tubal mole is found with continued bleeding. If villi do 
not grow, hemorrhage continues, since no contraction can take 
place as is the case in the uterus. The centrifugal form furnishes 
the majority of tubal ruptures. But the vast majority of these so- 
called tubal ruptures are either arrosions or are due to arrosion by 
the perforating villi. 

The Further Course of Ectopic Gestation. — The theory that 
the tube ruptures because the ovum is too big is, as a rule, wrong 
for cases in the first three months. The various interruptions of 
ectopic gestation are all the result of hemorrhages primarily minute. 
The usual ending, clinically, of the gestation begins with bleeding 
in the tube. The invasion of the vessels of the mucosa and the 
tube wall and the invasion of the serosa furnish the causes for 
hemorrhages. The death of the fetus, as in the case of the uterus, 
brings about changes which result in bleeding. The primary 
cause is a lack of decidua. In a mucosa previously affected, when 
many large vessels are changed by the fetal cells and invaded by 
villi, an increase in tension through contractions of the tube walls 
furnishes an easy explanation of this hemorrhage. In the uterus 
the vessels are firmly embedded in the thick decidua and take a 
twisted course; in the tube the vessels are straight and embedded 



64O MEDICAL GYNECOLOGY 

in loose connective or fetal tissue. Bleeding on the part of the 
capsule is possible and is of frequent occurrence, since it does not 
undergo decidual change and may be invaded by fetal cells. The 
contraction of the muscle fibers on either side of the capsularis 
renders the rupture of this pseudo-reflexa easy because of the ab- 
sence of decidual changes, and the point of rupture is usually at 
the summit of the capsularis. If the capsularis or reflexa be com- 
posed of muscularis and mucosa, a decided bleeding may result if 
only the summit of the capsularis be torn. 

Rupture of the tube almost always takes place at the placental 
site, which is the seat of old and new hemorrhages. The hemor- 
rhage and loosening of the ovum which represent the clinical end- 
ing of these cases is not the first bleeding, for older ones are usually 
present. The various processes depend upon the ovum, the con- 
dition of the tube before pregnancy, the character of the union of 
the ovum with the tube, the place of union, and trauma. The 
reaction of the tube is limited to the area of the ovum; and in this 
we find the main difference between tubal and uterine gestation. 
The uterus undergoes early independent growth; the tube does 
not. With the development of the ovum the uterus grows step by 
step, while in the tube the ovum makes room for itself and ob- 
tains its nourishment by the invasion of the tube walls. It may 
stretch the circumference of the tube so that its wall may be re- 
duced to a layer of connective tissue so thin that rupture may 
result at any point. 

Ampullar cases usually end in abortion, generally with hemato- 
cele. There is no obstruction, unless decided adhesions are pres- 
ent, and the blood is generally poured out quickly into the pelvic 
peritoneum or into the sac of Douglas. Such an abortion may be 
complete or incomplete. Rupture occurs in this situation very 
rarely. The majority of tubal gestations are situated nearer the 
isthmus tubae. In these cases we have: (1) Abortion without 
rupture, complete or incomplete, with bleeding from the abdominal 
end of the tube. Generally a hematocele is found at the abdominal 
end. The tubes are often so curved that it is difficult for the blood 
to make its way to the fimbriae, and the oozing is of a slow character. 
The blood extends rarely more than a very short distance toward 
the uterine end, because of the numerous short curves present 



•ECTOPIC GESTATION 641 

here. (2) We may have single or multiple microscopic perfora- 
tion of the tube wall by villi, causing even decided hemorrhage 
without apparent cause. (3) We may have macroscopic per- 
forations or "arrosions" of the tube wall, covered or not covered 
by thrombi, and causing great hemorrhage. (4) We may have a 
rupture either into the free abdominal cavity with no hematocele 
at the abdominal end of the tube, or with partial encapsulation, 
in which event there may be hematocele at the abdominal end if 
the tube is open. (5) We may have an intraligamentous tear with 
hematocele at the abdominal end. In these latter cases the pla- 
cental site is always on the inferior surface of the tube and the ovum 
has descended centrifugally to the vessels of the ligamentum 
latum. These and the interstitial forms are the most difficult cases, 
and may require hysterectomy to remove the mass in toto. 

We must not overlook the decided danger from continued bleed- 
ings involved in tubal abortion. The general view is that tubal 
rupture gives much more pronounced symptoms and a much more 
decided hemorrhage than tubal abortion. When we consider that 
incomplete abortion means that villi are left in the tubal wall, and 
that so-called complete tubal abortion means the retention of 
trophoblast cells, we may readily understand that bleeding may 
continue for an indefinitely long period. It is a fact, too, that 
even complete abortion may cause decided symptoms. Mandl 
reports two cases from the clinic of Schauta, accompanied by pro- 
nounced collapse and decided hemorrhage. In the first case no 
villi were found in the tube wall. In the second case, although 
villi were found in the blood-clot in the tube, none were found in 
the tube wall. Like cases of tubal abortion, with symptoms as 
severe as are frequently the rule with tubal rupture, have been re- 
ported by Klein, Zedel, Piering, and others. It seems to me 
that pathologic and clinical evidences are of sufficient weight 
to destroy the view, prevailing in many minds, that tubal rupture 
should be treated by extirpation of the tube, and that tubal abortion 
demands only conservative treatment. The proportion of tubal 
abortion to tubal rupture is probably 8 to 1. In this connection 
it is quite sufficient to mention the dangers arising from hema- 
tocele. The injury to the peritoneum, the adhesions which take 
place, and, above all, the by no means infrequent occurrences of 
41 



642 MEDICAL GYNECOLOGY 

subsequent purulent degeneration of such an accumulation of 
blood, are only some of the injurious results avoided by prompt 
removal. 

The possibilities are represented by the processes of abortion, 
microscopic perforation, macroscopic perforation, rupture, hema- 
tosalpinx, and tubal mole. In ninety-nine cases of interrupted tu- 
bal gestation in the clinic of Schauta, a hematocele was found sixty 
times — fifty-five after abortion, five times after rupture. If the 
bleeding be very slow, the blood forms a capsule, due to peritoneal 
adhesions, into which the subsequent hemorrhages enter, the so- 
called secondary hematocele. If adhesions are present at the 
abdominal end of the tube, they form a portion of the capsule. 
The hematocele resulting after rapid bleeding furnishes the primary 
or diffuse form. The secondary hematocele occurs much more 
frequently than the primary. In the sixty hematoceles found 
among ninety-nine cases in the clinic of Schauta, only four were 
diffuse. Of the tubal abortions found in the same clinic, seventy- 
five were incomplete and six were complete. 

Symptoms. — In ectopic gestation the breasts rarely show the 
same evidences as in intrauterine gestation. There may be pulsa- 
tion of the uterine arteries, but this is also present in intrauterine 
pregnancy and in other conditions, especially inflammatory. The 
passing of a decidua accompanied by bleeding occurs with tubal 
hemorrhage, tubal abortion, or tubal rupture, but here intra- 
uterine abortion and dysmenorrhea membranacea must be ex- 
cluded. It is always most important to ask about the occurrence, 
non-occurrence, or character of the last expected or skipped men- 
struation. There may have been relative amenorrhea or absolute 
amenorrhea, which latter is generally the case even if it lasts only 
for ten days or two weeks. Sometimes no change in menstruation 
has been observed. Uterine bleedings generally speak for disturb- 
ances in the tube, such as death of the embryo, hemorrhage, tubal 
abortion, or tubal rupture. These bleedings are usually followed 
by peritoneal irritation and by tubal and uterine colic. These 
sudden pains are not always felt in the pelvis, but sometimes higher 
up, even in the region of the liver. Combined with these symp- 
toms there is often nausea, pallor, dizziness, or fainting. The 
uterine bleeding may continue irregularly for days or weeks, often 



ECTOPIC GESTATION 643 

t 

with the above colicky pains, but the bleeding is not extremely 
profuse, clots are rarely expelled, and the blood is often brown and 
mixed with mucus. 

In contradistinction to intrauterine abortion it is noted that the 
cervix is not dilated. Examination of expelled structures shows 
no embryo, no fetal membranes, no chorionic villi. When decidua 
is expelled, microscopic examination may aid in the diagnosis. 
The decidua cells in ectopic gestation are not so large as in intra- 
uterine pregnancy. The cells are not mutually flattened and no 
chorionic villi are found. The microscope can make a positive 
distinction in favor of uterine pregnancy only by the finding of 
chorionic villi. 

Ectopic gestation may be diagnosed before bleeding, abortion, 
or rupture take place in the tube, or after one of these conditions 
has taken place. In the first instance bimanual examination finds 
a round or sausage-shaped dilatation of the tube which is soft, 
elastic and sensitive, and not so tense as ovarian tumors. This 
mass is movable unless adhesions are present. It resembles ad- 
nexal tumors, and a differential diagnosis is especially difficult 
from an intrauterine gestation combined with an adnexal tumor. 

In the second instance bleeding may take place into the tube, 
which then feels firm, hard, and movable, or into the cul-de-sac of 
Douglas, or if the bleeding occurs slowly and the blood coagulates 
it may accumulate about the tube. Bleeding in the tube or tubal 
abortion or tubal rupture produce peritoneal irritation. There is 
then a history of amenorrhea and of irregular menstruation or of 
irregular spotting or oozing. The decidua, if expelled, is generally 
cast off after tubal abortion or rupture has taken place. Examina- 
tion may show a soft resistance in the cul-de-sac of Douglas if 
there is free bleeding, or increased resistance about the adnexa if 
the bleeding is slow and encapsulated. 

If blood is accumulated in the cul-de-sac of Douglas, such a 
fresh hematocele is soft and cystic, but later on becomes hard. It 
is to be diagnosed from a retroflexion of the gravid uterus. A 
hematocele pushes the uterus forward. As Winter says, the 
whole of the uterus is in front of the tumor, whereas in retroflexion 
of a gravid uterus only the cervix is in front. In retroflexion of 
the gravid uterus the connection between the cervix and the 



644 MEDICAL GYNECOLOGY 

soft, pregnant, retroflexed fundus in the cul-de-sac of Douglas is 
not made out, and the cervix is mistaken for the uterus and the 
retroflexed fundus is mistaken for a hematocele. 

A peritubal hematocele is situated generally postero-lateral to 
the uterus, is of irregular outline, soft in the earlier stages, and 
later on harder and firm and may be so large as to extend above 
the umbilicus. 

Intraligamentous hematocele has probably no other cause than 
the rupture into the broad ligament of a tubal pregnancy. With 
marked bleeding into the peritoneal cavity of a rapid nature the 
symptoms are those of internal hemorrhage and constitute the 
tragic form of this condition. 

The Early Diagnosis of Ectopic Gestation. — Because of our 
complete accord on this important topic, I quote in the remainder 
of this section the views of Philander Harris : " There are instances 
in which the first complaint of the patient, and the first symptoms, 
are of such nature as to excite the greatest alarm in the minds of 
physician and friends of the patient, because the patient is, without 
previous warning, brought at once to the verge of death; yet such 
cases are very exceptional. Such symptoms occurring progres- 
sively or suddenly are called the tragic symptoms of ectopic ges- 
tation. 

"Twenty-nine out of every thirty cases of ectopic gestation 
present symptoms by which a presumptive, if not a reasonably 
certain, diagnosis may be made prior to the patient's arrival at a 
condition which is alarming. Most cases present a group of symp- 
toms preceding the tragic stage of the disease sufficiently distinc- 
tive to warrant a diagnosis, and since these symptoms are in no way 
alarming, they are called the non-tragic symptoms of ectopic gesta- 
tion." Based on an experience of over one hundred cases, Harris 
came to the following conclusions : 

(a) More than 90 per cent, consulted a physician on account 
of symptoms referable to the pelvis before the tragic 
stage was reached. 

(b) Many of them received medical advice or attendance for a 

term of several weeks before tragic symptoms presented. 

(c) Many such cases are not diagnosed, and although the 

patients continue to exemplify the symptoms of the non- 



ECTOPIC GESTATION 645 

tragic stage of ectopic gestation, they rely for days or 
weeks upon false hopes until the tragic symptoms occur. 

(d) Of the 90 per cent, who consulted a physician a very 
large proportion were told that an (ordinary) abortion 
was threatened, was recurring, or had occurred. 

(e) Of the 90 per cent, who consulted a physician, about 20 

per cent, were subjected to the operation of curettment 
for the cure of metrorrhagia, the real cause of the metror- 
rhagia not having been suspected. 
(/) Of the 90 per cent, who consulted a physician, some were 
unable to pursue their usual vocation, being confined to 
the bed or couch for days or even weeks before tragic 
symptoms occurred. Except for brief intervals of an 
hour, or a few hours or so, a large proportion 0} the cases 
oj ectopic gestation pursued their usual vocation during 
the non-tragic stage without material or prolonged in- 
terruptions. 
"When any woman after puberty and before menopause who has 
menstruated regularly and painlessly, goes four, five, six, eight, ten, 
fifteen to eighteen days over the time at which menstruation is due, 
sees blood from the vagina differing in quality, color, quantity, or 
continuance from her usual menstrual flow, and has pains, generally 
severe, in one side of the pelvis or the other, or possibly in the hypo- 
gastric region, ectopic gestation may be presumed.'''' 
The two symptoms of greatest value are : 

(a) Atypical menstruation, or metrorrhagia. 

(b) Pains. 

The expression "atypical menstruation of ectopic gestation" 
directs attention to the appearance of blood generally out of rhythm 
with the normal menstrual cycle of the individual. The amount 
of blood lost may be very much greater, or very much less, than the 
usual menstrual flow of the patient. It may be continuous or 
appear with interruptions. It may be darker or may be lighter or 
more brownish than the usual menstruation. 

The metrorrhagic blood of ectopic gestation very often has a 
sort of slippery character, almost sufficient at times to diagnosticate 
ectopic gestation by the effect of such discharge upon the tactile 
sense. 



646 MEDICAL GYNECOLOGY 

History. — 1. Note if the patient's present or last menstruation 
was out of type. 

2. Note the date, duration, amount, and character of the men- 
struation preceding the atypical menstruation, and of the menstru- 
ation before that one too. 

3. Note the date of each colic or series of colics, and the datcor 
dates of any recurrence. 

If the patient has been accustomed to painful menstruation, 
analyze the character of her dysmenorrhea, and ask her particularly 
if the pains which appeared in connection with the blood at this 
time were the same as the usual pains of her dysmenorrhea. If the 
patient is intelligent, she will at once say that she never had pains 
like these, and she will at once tell you wherein the pains and the 
flow of her present attack differ from her previous and painful 
menstruations. Morning sickness and enlargement of the breasts, 
which are the ordinary symptoms of intrauterine pregnancy, do not 
belong to the symptomatology of the extrauterine pregnancy. If, 
with a diagnosis of miscarriage, the patient is still bleeding and 
has pains, be slow to accept such a diagnosis, unless a fetus has 
actually been seen by some one. 

If the colics are very severe with steady pains between them, the 
abdominal walls may be rigid. The colics in the beginning of 
tubal pregnancy are often mistaken for intestinal pains. They may 
not cause the patient to rest more than momentarily from her work 
or pleasure. In other cases the pains are so severe and agonizing 
that the doctor is at once sent for, whatever the time of day or 
night. Soreness of the abdomen may pass off in an hour or less 
after a severe ectopic gestation colic, or it may be so prolonged as to 
prevent the patient from walking for a day or two, or longer. Oc- 
casionally jars of the body in walking, or being much upon the 
feet, cause so much pain that the patient remains in bed for a 
while. In such cases the colics may return after shorter or longer 
intervals. 

Sometimes colics and the atypical menstruation of ectopic gesta- 
tion appear before the menstruation is due, or just at the time that 
it is due. Such a history is rather unusual, and in the absence of 
tragic symptoms, such as a rapid and weak pulse, fainting, and 
pallor of the skin, may offer very little presumption of the true 



ECTOPIC GESTATION 647 

condition present until we have waited a sufficient time to rind 
whether the menstruation is of the usual type for that individual. 

Colics and the sharp pains of ectopic gestation are generally closely 
attended by the appearance of a bloody discharge from the vagina. 

The Non-tragic Stage. — In this stage of ectopic gestation the 
pulse usually remains about normal. If, however, within a few 
hours a sufficient quantity of blood is lost in the abdomen, the 
pulse will be found quickened, the patient weakened, and the tem- 
perature below normal, and the amount of blood thus lost to the 
circulation may be sufficient to at once cause alarm or imperil 
life. If so, the tragic stage has been reached. 

The temperature of the patient in the non-tragic stage of the 
disease, like the pulse, is not materially affected, unless a con- 
siderable amount of blood has escaped into the peritoneal cavity. 
In that event there sometimes occurs, a few days after extensive 
bleeding in the peritoneal cavity, some elevation in temperature, 
generally not more than a degree or so. It should be said that the 
symptoms of the non-tragic stage may be present for days or weeks 
before any considerable amount of blood is found in the abdominal 
cavity. During all this time the temperature may not be materially 
altered from the normal. 

The Tragic Stage. — The tragic stage of the disease is. exemplified 
by severe colics, pallor of the skin, weak and rapid pulse, a fall of 
temperature one, two, or three degrees below normal, rapid breath- 
ing, fainting, generally vomiting and restlessness, and sometimes a 
lethargic condition from which the patient may be aroused. In 
this tragic stage the pulse may be anywhere from 120 to 180. It 
may not be possible to count it at the wrist, although its flickering 
may be perceived until shortly before death. 

Physical Examination. — No disease produces in the pelvis 
such a variety of conditions to be palpated by examining fingers 
and hands as does ectopic gestation. Ectopic gestation always 
increases, in a slight degree at least, the size of the uterus. It is 
exceptional for the uterus to become very much enlarged. The 
cervix is generally not altered by tubal pregnancy, but this rule has 
some exceptions. Most uteri of ectopic gestation are not very 
materially altered in size, shape or consistency, from the non- 
pregnant condition. Unless hematocele has formed, the mobility 



648 MEDICAL GYNECOLOGY 

of the uterus may not be particularly affected. If the uterus is 
lifted by the examining finger, pain is almost always produced on 
the side of the pregnant tube. 

In the non-tragic stage the pregnant tube is usually sufficiently 
large to be palpated, and possibly also approximately measured by 
bimanual palpation. Operation in the non- tragic stage of the 
disease may show the tube at its largest diameter to not exceed 
one-half of an inch. The tube may so enlarge from the growth of 
the fetus within it, and from hemorrhage between the fetal mem- 
branes and the tube wall, as to increase its diameter to two inches or 
more. The tube may become distended from hemorrhage within 
it, without any considerable amount of blood reaching the perito- 
neal cavity, and the patient had consequently not yet exemplified 
the symptoms which characterized the tragic stage of the disease. 

A pregnant tube is always tender when squeezed, and may be 
extremely painful when so treated. The tube may be embedded 
in blood-clots, or so displaced, or partly or completely engulfed 
in hematocele, that its form and size are indistinguishable. 

If a large hematocele has formed, the uterus may be carried far 
upward and almost out of the pelvis. When thus lifted it is gener- 
ally pushed to the opposite side from that in which the tubal preg- 
nancy exists. The hematocele may be so large and the uterus so 
far pushed up that the cervix will with difficulty be reached by the 
index-finger per vaginam. 

The corpus and fundus uteri resting on the outer and anterior 
surface of a large hematocele may be distinctly palpated through 
the abdominal wall. In one instance the uterus was visible as it 
rested upon a large hematocele and lifted the abdominal wall. 

Differential Diagnosis. — The following are some of the con- 
ditions from which tubal pregnancy must be differentiated : 

(a) Uterine abortion. (See pp. 563, 640.) 

(b) Salpingitis. 

(c) Uterine polypus and submucous and interstitial fibroid of the 
uterus. 

(d) Cancer of the uterus. 

(e) Ovarian cyst with twisted pedicle. 

(/) Progressive intrauterine pregnancy accompanied by metror- 
rhagia. 



ECTOPIC GESTATION 649 

Salpingitis. — A quite common result of salpingitis is shortening 
of the intermenstrual term and a lengthening of the menstrual flow, 
with increase in the quantity of blood lost at menstruation. 

It is not at all unusual for a patient with acute salpingitis to have a 
lengthened term of menstruation, and to have it followed for a num- 
ber of days with a metrorrhagia. If by the time we first see such 
a case the initial fever of her infection has passed away, and we 
then find her temperature normal, we may wrongly conclude that 
her symptoms are those of the non- tragic stage of tubal pregnancy. 

If the salpingitis has existed for months or years, the patient may 
have suffered from pelvic pains, and such a history will of course 
place us upon our guard, for she may present the symptoms of 
salpingitis, to which, in consequence of ectopic gestation, are added 
the symptoms of the latter condition, or she may have only the 
former disease. 

The patient with chronic salpingitis rarely goes over her time of 
menstruation. If there is any change in the length of time from 
beginning to beginning of menstruation, it is more likely to be 
shortened, while the duration and amount of the flow are increased. 

Salpingitis disposes many women to menstruate ahead of time; 
ectopic gestation apparently delays the last or alleged menstrua- 
tion, and when it appears it differs in one or several particulars 
from the previous menstruation of the individual. 

A very considerable percentage of women who have tubal preg- 
nancy are found, when operated upon, to have diseased tubes. 
Therefore, in a certain percentage of the cases of ectopic gestation 
there are two symptom-producing factors, namely, salpingitis and 
pregnancy within a tube. 

I believe that not very gross pathologic changes accruing from 
salpingitis constitute the chief, if not the only, cause of ectopic gesta- 
tion. If this be true, then a certain percentage of cases of tubal 
pregnancy will exhibit .to a certain extent the symptoms of salpin- 
gitis together with the symptoms of pregnancy within the tube. 

The failure to always differentiate tubal pregnancy and sal- 
pingitis is of little consequence, for the reason that in either case 
an operation is undertaken in the interest of the patient, and while 
the abdomen is opened the pathologic condition can be removed. 

Uterine Polyps. — Uterine polyps produce menorrhagia and 



650 MEDICAL GYNECOLOGY 

metrorrhagia, but they are not prone to produce colics. Intrauterine 
fibroids cause menorrhagia and metrorrhagia, and to a certain ex- 
tent pains, which might be mistaken for the slighter colics of tubal 
gestation, but none of these conditions arising from neoplasm are 
very likely to produce the severer colics of ectopic gestation. 

Carcinoma. — Cancer of the uterus is not always productive of 
pain, but when it produces pain as well as metrorrhagia, the history 
may be quite like the history of non-tragic stage of ectopic gesta- 
tion. The physical examination and finding a painful tube or 
tumor at either side of the uterus, together with inspection of the 
cervix, eliminate doubtful points in diagnosis. 

Ovarian Cyst. — Ovarian cysts with twisted pedicle cause men- 
struation to be atypical and produce metrorrhagia. The excru- 
ciating colics, the steady pain, the soreness of the abdomen, and 
the metrorrhagia which so often follows the twisting of a pedicle, 
afford one of the best counterfeits of ectopic gestation. Such cases 
are, of course, comparatively rare, and are not difficult to diagnos- 
ticate, unless the tumor which is twisted on its pedicle was not known 
to exist prior to the colics and to the atypical menstruation. 

Metrorrhagia without abortion may occur for two, three, four, 
or five weeks in the earlier course of progressive intrauterine 
gestation. The absence of colics, and possibly the presence of 
morning sickness, the very soft condition of the cervix, a gradually 
enlarging uterus with no special pain at either side of it, make the 
diagnosis. 

The treatment of ectopic gestation is abdominal laparotomy as 
soon as the diagnosis is made, provided the patient is not in too 
profound a state of shock from the sudden loss of great amounts 
of blood. These extreme cases, which constitute a small percentage, 
are operated on immediately by some, an intravenous saline solution 
begin given before or during the operation. I agree that such 
cases should be tided over the state of shock by repeated hypoder- 
moclysis, absolute quiet, elevation of the foot of the bed, and not 
too energetic cardiac stimulation for a period of twenty-four hours 
to several days, when the operation is sure to be better borne. 
After operation, conservative treatment and a long period of steril- 
ity are essential to avoid ectopic pregnancy in the other tube, if its 
condition did not warrant removal at the time of operation. 



DISEASES OF THE OVARY 

Interstitial Oophoritis. — Interstitial oophoritis is of the acute 
form and of the chronic. The acute inflammation is chiefly caused 
by a septic or gonorrheal infection and causes a well-marked small- 
celled infiltration of the interstitial tissue with hyperemia and in- 
crease of the vessels. Extravasation of blood into the tissue may 
result, and if at the same time there is an entrance of pyogenic 
bacteria, formation of pus takes place. Suppuration involves 
either the entire tissue, the pus changing the entire ovary into a 
large abscess cavity (ovarian abscess) by breaking through the 
walls of the follicle, or else the suppuration is confined to indi- 
vidual parts. In this way there results suppuration of the corpora 
lutea and the formation of corpus luteum abscesses (Abel). 

In the chronic form of interstitial oophoritis there results the 
formation of connective tissue with sclerosis; the follicles are de- 
stroyed and the stroma shows fibrous connective tissue. 

It is not to be doubted that the diseases of childhood may be re- 
sponsible for chronic alterations in the structure of the ovaries. In- 
fectious diseases like typhoid are likewise a cause of structural 
alteration. Intraperitoneal conditions, however, are a very fre- 
quent cause of isolated ovarian involvement. The peritoneal irri- 
tation and peritoneal exudation associated with milder or severer 
degrees of appendicitis or of tuberculosis result in infection of the 
follicles and in interstitial inflammation of the ovaries. Upward 
extension of inflammation from the uterus in the gonorrheal in- 
fection of children and in the subacute upward extension of gonor- 
rhea or other inflammation in adults, either through the tubes or 
through the broad ligaments (paraoophoritis) is a frequent cause of 
ovarian involvement with or without the production of adhesions, 
especially after curettage. In such cases we often have single 
or multiple Graafian follicle cysts or tubo-ovarian cysts. (See 
Ovarian Dysmenorrhea.) 

Cystic Changes. — Cystic ovarian changes may be due to re- 
tention of fluid in the Graafian follicles or corpora lutea, generally 

651 



652 MEDICAL GYNECOLOGY 

as a result of ovarian inflammation or of infection of the follicles. 
They may be due to inflammatory changes which involve the tube 
and ovary, resulting in the formation of a tubo-ovarian cyst. They 
may be due to proliferating changes occurring in the epithelial 
components of the ovary as a result of growth of the epithelial 
elements of the Wolffian body originally present in the formation of 
every ovary, thus producing cystadenomata. They may be due to 
the displacement of fetal cells, resulting in the formation of a der- 
moid cyst. In addition, there are the so-called solid tumors of 
the ovary. 

Retention Cysts. —Retention cysts originate, as a rule, in con- 
sequence of chronic inflammatory changes in childhood or later. 
Through the resulting hyperemia there occurs a serous exudation 
from the vessels and an effusion of serous fluid into the follicles. 
In advanced cases the greater portion of the interstitial tissue may 
be replaced by cysts. The cysts, as a rule, attain the size of a ripe 
Graafian follicle. The lining of the follicles plays only a passive 
role. Interstitial oophoritis is the most frequent cause of follicle 
cysts. The ovary contains numerous follicles of various sizes. 
Retention cysts, then, are inflammatory cysts and there occurs a 
"cystic degeneration" of the ovary, often associated with visible 
diseases of the tubes and with mild adhesions. This condition is 
generally bilateral. The entire ovary is distended and its surface 
is irregular. If the condition continues, one follicle may overtop 
the other, may cause them to atrophy, and result in the formation 
of a large Graafian follicle cyst. 

Graafian Follicle Cysts.— Large Graafian follicle cysts begin 
either as a single cyst or else one cyst of the inflammatory, cystically 
degenerated ovary grows excessively, overtops the others, causes 
their atrophy, so that finally there results a cyst the size of a walnut 
up to the size of a child's head, consisting of only one chamber with 
smooth lining, and containing a clear fluid, and with an extremely 
thin, almost transparent wall and lined by cuboidal cells. Part of 
the ovary is generally retained at the hilus. 

Corpus Luteum Cysts. — Corpus luteum cysts vary in dimen- 
sion from the size of a large walnut up to the size of an orange, 
with a thick wall and a yellow or brown irregular lining. Corpus 
luteum cysts are said to occur under circumstances which we do not 



DISEASES OF THE OVARY 653 

yet understand. The cyst contents come through serous exudation. 
They are probably due to infection of a ruptured follicle and have 
the same origin as some of the retention cysts. 

Tubo-ovarian Cysts. — Large follicle cysts with a hydrosalpinx 
form a tubo-ovarian cyst. Tubo-ovarian cysts are therefore in- 
flammatory cysts of the ovary combined with hydrosalpinx. The 
abdominal end of the tube is attached to and is adherent to the 
ovary. The ovary is dilated into a large unilocular or multilocular 
cyst by infection of the follicles. Such tubo-ovarian cysts are situ- 
ated posterior to the broad ligament and are often fixed far over to 
the lateral wall of the pelvis, and are exceedingly adherent to the 
floor of the pelvis and to the sigmoid flexure. They often become 
so closely attached to the posterior wall of the broad ligament that 
they seem to be situated within the folds of the broad ligament, 
and are therefore pseudo-intraligamentous. They are often double- 
sided, in which case there is a vast difference in their size and 
development; one side usually being much smaller, less adherent, 
and much less developed than the other. 

Parovarian Cysts. — Parovarian cysts are unilocular cysts 
with a thin wall containing a clear fluid, situated within the broad 
ligament and therefore intraligamentous. Upon the external sur- 
face is found a long straight tube and a portion of the ovary. They 
develop from the parovarium, which is situated in the hilus of the 
ovary in the mesovarium. 

Proliferating Ovarian Tumors. — Proliferating ovarian tumors 
are tumors of active growth developing from epithelial structures 
situated within the ovary. These tumors have been said to de- 
velop from the Graafian follicles or from the surface epithelium of 
the ovary. However, they probably develop from remnants of the 
Wolffian body situated in the ovary. They are of two forms: 

1. Glandular Cystoma. — Cystoma glandulare or cystadenoma 
pseudo-mucinosum, containing watery, honey-like, or jelly-like con- 
tents. Even the watery fluid has a sort of syrupy, sticky consist- 
ence. Because the inner lining shows glandular proliferation it is 
called cystoma glandulare or cystadenoma. Because the contents 
contain pseudo-mucin, and because the contents are sticky, even 
if watery, and often of honey-like or jelly-like consistence, the 
name cystadenoma pseudo-mucinosum is given. 



654 MEDICAL GYNECOLOGY 

They all contain pseudo-mucin. The wall of the cysts consists 
of an outer layer of germinal epithelial nature; that is, of the outer 
structure of the ovary. The middle layer consists of connective 
tissue; the inner layer consists of epithelium. Microscopically 
there are cavities, and tubules lined with epithelial cells of high 
cylindrical character with nuclei at the base of the epithelium 
project in microscopic papillary form into the cyst cavity. 

These tumors are the most frequent form of ovarian cysts. The 
tumors are of various sizes, from small cysts to extremely large 
ones. The entire ovary is involved. Usually there is a main cyst 
and many smaller cysts, but the outer surface is formed by a com- 
mon capsule. The surface is smooth if the cyst is composed of 
one chamber. The surface is irregular if the tumor is composed of 
several chambers. The form is ovoid or spherical, but sometimes 
when multilocular it is irregular. The smaller tumors may feel 
firm and hard, but the larger ones have a cystic feel. These tumors 
are generally unilateral and pedicled. They may be adherent to 
omentum and intestine. 

Cystadenoma pseudo-mucinosum is the most frequent form and 
produces the largest tumors. They are generally found between 
the thirtieth and fiftieth years. Unmarried and sterile women 
are especially disposed. 

Metastases may occur with cystadenoma pseudo-mucinosum. 
There may occur jelly-like tumors with very thin walls in the 
peritoneal cavity. If a cystadenoma pseudo-mucinosum ruptures 
spontaneously or at operation, there may occur such cystic jelly- 
like tumors in various areas of the peritoneum, which condition is 
called pseudo-myxoma peritonei. 

2. Papillary Cystoma. — Cystadenoma serosum or cystoma 
papillare. They are called cystadenoma because of the epithelial 
proliferation. They are called cystadenoma serosum because of their 
thin, clear, fluid contents. Because of the papillary epithelial 
growths on their inner surface they are also called papillary cystoma. 
This form is generally multilocular and contains no- pseudo-mucin. 
It is characterized by papillary growths, in that on the cyst lining 
there are projections formed of epithelium ciliated in character. 
The entire cyst may be lined with papillary outgrowths of the 
character of cauliflower. The cyst may be filled with such masses. 



DISEASES OF THE OVARY 655 

The tumors may be of any size, up to that of a man's head. They 
have an irregular surface. They are often double- sided and not 
rarely intraligamentous. They often cause ascites. Through 
energetic epithelial growth, the epithelial masses penetrate the 
wall and extend up to the peritoneum. These cysts are dangerous 
because the papillary excrescences have marked tendency to grow 
through the wall of the cyst. Therefore these tumors are often 
adherent and the papillary growths produce peritoneal metastases 
of the same character. When the papillary excrescences per- 
forate the cyst wall, ascites is frequent and the tumor constitutes 
a malignant form. The early metastases of papillary tumors, 
however, may disappear after removal of the original tumor. 

Dermoid Cysts. — Dermoid cysts are cysts varying in size from 
that of an egg to that of a child's head. They contain fat, epi- 
dermis, hair, bone, teeth, etc., and on microscopic examination 
contain muscle tissue and various forms of glandular tissue. They 
often feel hard or solid and are generally adherent. 

Teratoma is really a solid dermoid containing the same variety 
of tissues, with the exception of hair and epidermis. There- 
fore they are not cystic, but are solid. 

The origin of dermoids is to be referred to fetal cells displaced 
into the ovary by the Wolffian body in the course of embryonal 
development. 

If ectodermal cells are displaced to any extent, so that their pres- 
ence is manifested by cutis-like tissue, hair, sebaceous glands, etc., 
we speak of dermoid cysts. If the displaced cells are, so to speak, 
located in one part of the organ concerned, and if they grow equally, 
and if the skin cells, as in the normal skin, and the sebaceous 
glands, excrete their products, a cystic dermoid must result. Since 
the contents found in dermoid cysts are excreted by the so-called 
"derm" of the cyst, they must lie, when secreted, between the derm 
and the enveloping tissue composing the organ or tissue in which 
the dermoids grow. The larger the amount of secretion, the greater 
is the pressure exerted on the surrounding tissue. If the mass of 
secreted matter reaches a fair amount, and if it causes a tissue 
growth in its periphery, and if it distends the enveloping organ 
or tissue so that it is stretched and flattened, we then have a cystic 
dermoid whose wall consists of so-called "skin," of granulation 



656 MEDICAL GYNECOLOGY 

tissue, and of the tissue of the enveloping organ. The original 
group of displaced cells is found then as a prominence only in one 
part of the so-called cyst, in which are formed the hair, the seba- 
ceous glands, and the other elements found on the inner surface 
of a dermoid cyst. The greater the amount of substance secreted, 
and the greater the amount and number of products formed by the 
displaced ectodermal and mesodermal cells, the larger is the cyst. 

If, on the other hand, the displaced cells are not grouped in one 
part of the organ concerned, and if, at the same time, the ectoderm 
cells are not present in too great number, there develops a tumor in 
which the various forms grow into each other. Since the ectoderm 
cells do not form in such a case a so-called "derm," and since they 
cannot bring about the formation of a cyst through sebaceous ex- 
cretion, as above described, a tumor form results which is rela- 
tively solid and which seems to be of an entirely different struc- 
ture — a so-called "teratoma." 

The so-called "mixed tumors of the ovary" are the following: 
enchondroma and osteoma, which are rare; cystic sarcoma, 
myxofibroma, adenomyxocy stoma. In comparison with the mixed 
tumors of the testicle they are rare. A comparison of the mixed 
tumors found in the ovary with those in the testicle shows that in 
the latter there is a prevalence of mesoderm products with a rela- 
tively infrequent presence of ectoderm elements. In the ovary, 
however, these tumors occur more frequently in the forms of der- 
moid cysts than in the testicle. This may be explained by the 
fact that in the female the Wolffian duct and the Wolffian body lie 
at the hilus as non-functionating organs, while in the male they 
form the vas deferens and functionating tubules. 

That enchondromata and osteomata occur frequently in the 
ovary seems to be overlooked, because these, almost without ex- 
ception, occur in combination with ectoderm cells, i. e., as dermoid 
cysts and solid dermoids. This difference is explained, as above, 
by the fact that the Wolffian body and duct in the female remain 
as regressive structures and are more liable to growth on their 
own part and on the part of the cells which they have displaced. 
On the other hand, the Wolffian duct in the male forms the vas 
deferens, and a portion of the Wolffian body forms the head of the 
epididymis and the rete testis, while only a part undergoes 



DISEASES OF THE OVARY 657 

regressive changes, and this part has not, like the Wolffian duct, 
been in close contact with ectoderm. 

In ovarian dermoids and teratoma ta, ectoderm is present. 
Therefore teeth are frequently found, and their occurrence is in 
contrast with their rarity in the testicle. 

In dermoid cysts the teeth are embedded in bone, or in the wall 
of the cyst where no cartilage or bone is to be found; they may 
also lie in the cyst contents. Their number varies, even one 
hundred or more having been found in the cyst. The teeth lie, as a 
rule, on the inner surface of the cyst, and are rarely embedded com- 
pletely within the wall; another fact which speaks for their origin 
as explained above, for ectoderm or skin is found on the inner 
surface. A further interesting fact is that the teeth, in all cases 
which we have examined, are always unilateral, and, with perhaps 
one exception among eleven cases which were examined for me 
by a skilled observer, correspond to that side of the bod}' in which 
the cysts are found, i. e., in right-sided cysts were found right- 
sided teeth; in left-sided cysts, teeth of the left side. The oc- 
currence of teeth in dermoid cysts is not limited to the ovary alone, 
for they are found in dermoid tumors in the brain, the eye, the 
mediastinum, and in abdominal dermoids. The teeth may be 
either first or second teeth, and both forms may be found in the 
same tumor. They may be molars, bicuspids, incisors, etc., and 
may represent the teeth of the upper or lower jaws. 

The dermoid cysts of the ovary do not always take their origin 
from the ovary. If, however, they do, the ovary may be entirely 
dilated by the tumor which has developed in it. On the other hand, 
the ovary may be found only in one part of the cyst wall in cases 
where the dermoid cyst originated at the hilus and grew into the 
broad ligament. Dermoid cysts may develop in the broad liga- 
ment and the ovary takes no part in the formation of the tumor, 
but lies absolutely free, showing, however, as a rule various changes. 

The cells from which dermoid cysts develop may be carried into 
various parts of the ovary, so that several dermoids are present. 
Olshausen found in one case a proliferating cystoma of the ovary 
with a dermoid cyst of the size of an egg. In another case he 
found three dermoid cysts side by side. Wilms reported a case 
where five small dermoid cysts were present in one ovary. 
42 



658 MEDICAL GYNECOLOGY 

Dermoid cysts of the ovary frequently contain, in addition to 
epidermis and hair, smooth muscle fibers, cartilage, bone, teeth, 
connective tissue, neuroglia cells, structures like spinal ganglia, 
and cysts. The latter may be lined with simple or stratified cyl- 
indric epithelium or with ciliated epithelium. The inner surface 
of the cysts may show papillary excrescences, or may be lined with 
crypts containing beaker cells. In other words, we find micro- 
scopically in these dermoid cysts the same glandular structures as. 
are found in the various adenomata, cystomata, and cystadenomata 
of the ovary whose origin we have referred to the Wolffian body 
tubules. 

Among other interesting structures found in dermoid cysts must- 
be mentioned nails (finger-nails), of which very fine specimens are 
to be found in the museum of the Anatomical Institute of Vienna. 
Olshausen says: "It should not be considered strange if nails be- 
longing to the skin are frequently found in dermoid cysts. The 
collection in the Gynecological Clinic in Halle contains a speci- 
men of a dermoid cyst of a goose containing a large number of 
feathers." 

Dermoid cysts are frequently combined with proliferating cys- 
tomata. As a rule, a cystoma is found in the same ovary in addi- 
tion to a dermoid cyst, but more frequently there are found in the 
walls of the dermoid cyst smaller or larger formations of the same 
character as in simple proliferating cystoma. These two forms are 
to be distinguished from these combinations of two separate tumors, 
the one a dermoid, the other a cystoma, united through adhesion 
and perforation of the separating walls. The occurrence of a der- 
moid in one ovary with a cystoma in the other is by no means rare. 
Olshausen quotes a case of Flaischen in which a proliferation of the 
connective tissue was present in the same ovary; the walls of the 
cyst showed sarcomatous degeneration. A case of Unverricht 
showed, in the left ovary, the characteristic elements of a dermoid, 
and also red, spongy masses which were included as distinct 
nodules in the connective-tissue capsule. The case presented a 
round-celled sarcoma. Tumors of the same form were found in 
the cervix, peritoneum, omentum, liver, and diaphragm. Al- 
though the tumors in these latter situations are to be considered 
metastases, that in the cervix probably originated from the Wolffian 



DISEASES OF THE OVARY 659 

duct, in the same way as the main tumor in the ovary. That 
dermoids and teratoma should form metastases and undergo 
malignant degeneration into carcinomata, etc., is very natural, 
for they are nothing else but the cells of the patient, and may, 
therefore, pass through the same changes as the normally situated 
cells of the body. 

Solid Tumors. — The solid tumors of the ovary are fibroma, 
sarcoma, true carcinoma, papilloma, endothelioma, and teratoma. 
With myoma or malignant tumors of the uterus the ovaries are 
hyperemic and edematous. In ovarian fibroma the ovarian tissue 
is replaced by fibrous connective tissue. The external form of 
the ovary is usually preserved. Such changes are most often ob- 
served with uterine myomata. Myomata of the ovary are rare, 
and when they occur are usually mixed tumors. They are usually 
round-celled and of soft consistence. Papillomata are solid tumors 
of the form which also occurs when the cyst wall is perforated by 
the papillary growths in the cyst with papillary cystomata. Car- 
cinoma of the ovary has an irregular surface, early ascites, many 
adhesions, and peritoneal metastases. No sharp clinical distinc- 
tion is made by most surgeons between pure carcinoma and solid 
papilloma. 

DIAGNOSIS 

In chronic oophoritis the ovary is rarely larger than a hen's egg. 
It is sensitive and other inflammatory evidences may be present. 
In making the diagnosis of chronic oophoritis, the ovary must be 
felt to be structurally altered and to be painful and sensitive on 
pressure. Care must be taken not to include in this class an ovary 
containing a Graafian follicle about to burst, which gives on the 
first bimanual examination evidences of an enlarged sensitive ovary. 
Repeated examinations must show an ovary to be constantly al- 
tered. Small cystic degeneration is evidenced by a hard, tense 
feel and an irregular surface. In the smaller cystic conditions of the 
ovary the cystic consistence is generally lacking. Such an ovary is 
found only on careful bimanual examination. It may be situated 
in the normal location of the ovary, but very often it is posterior to 
the uterus or situated in the cul-de-sac of Douglas. These smaller 
conditions are of various sizes and are with or without adhesions. 



660 MEDICAL GYNECOLOGY 

This change in the ovary is often the cause of ovarian dysmenor- 
rhea, of intermenstrual ovarian pain, pain felt in the hips, the 
thighs, the back or under the ribs. (See page 159, 232.) 

An intraligamentous cyst is situated in the broad ligament close 
to the uterus, extending up to the pelvic wall. When large it bulges 
down into one lateral fornix. It has a rounded upper surface and 
has little mobility. The uterus is often pushed away from the 
median line. A pseudo-intraligamentous cyst is a retroligamentous 
tumor fixed to the floor of the pelvis and to the broad ligament, 
which is situated on its anterior and upper surface. The anterior 
surface of the cyst is often so closely attached to the broad ligament 
as to make the tumor seem intraligamentous. 

Intraligamentous cysts are of limited mobility. They cannot 
be pulled or pushed out of the pelvis. They are situated close to 
the uterus. The folds of Douglas are situated median to them 
and posterior to them; while in retrouterine tumors the fold of 
Douglas is anterior to the tumor. With intraligamentous tumors 
the connection of the cyst with the uterus is thinner than the beefy 
connection of an intraligamentous myoma. Intraligamentous 
cysts must be diagnosed also from pseudo-intraligamentous tubo- 
ovarian tumors, from intraligamentous hematoma, etc. 

Ovarian tumors must especially be diagnosed from pedicled 
myomata. Ovarian cysts have a cystic feel, but are often hard; 
especially is this the case with dermoid cysts of the ovary. In 
order to make out the pedicle, the tumor should be pushed up into 
the abdominal cavity and the uterus pulled down by volsella. As 
a rule, ovarian tumors have a thin membranous pedicle, while 
fibromata have a thicker, rounder, and more meaty pedicle. If with 
a cystic tumor two normal ovaries can be palpated, the diagnosis of 
pedicled nbromyoma is made. 

With ovarian cysts oj large size a, differential diagnosis must be 
made from encapsulated ascites due to tuberculosis, from the ascites 
of carcinoma, and from peritoneal exudate. The main point is 
to feel a pedicled connection with the uterus. The uterus should 
be pulled down by tenaculum forceps to make the pedicle tense and 
an assistant should pull the tumor upward. Then with one or two 
fingers introduced into the rectum the external fingers should meet 
the fingers situated in the rectum between the uterine horn and 



DISEASES OF THE OVARY 66 1 

the tumor. In this way the pedunculated character of the tumor 
and the character of the pedicle can be made out. The horn of the 
uterus on the side from which the tumor comes is less movable 
than the other one. Diagnosis is aided by percussion, by palpation, 
and by inspection of the abdomen. In encapsulated ascites there 
is not such a round contour and nodules may be felt. A tympanitic 
resonance may be obtained as a result of the adherent intestine 
situated over the encapsulated fluid, and there is a less clearly 
outlined tumor than is the case with ovarian cyst. A distended 
bladder may be excluded by the use of the catheter. Echinococcus 
cyst usually shows an associated involvement of the liver. Preg- 
nancy of the fourth or fifth month, especially if the uterus is ante- 
flexed, demands a differential diagnosis from ovarian cyst. The 
portio seems separated from the fundus by the area of Hegar and 
the portio may be mistaken for the uterus. By examination through 
the vagina and through the rectum there must be proved a con- 
tinuation of the portio into the pregnant fundus. If the fundus of 
such a pregnant uterus is situated laterally, it resembles an intra- 
ligamentous cyst. The history of amenorrhea, morning nausea, 
the evidences of ballottement, and bluish discoloration of the vagina 
are points of importance. Often these cases must be watched for 
weeks until fetal movements and the beating of the fetal heart in 
the second half of pregnancy make the diagnosis of pregnancy 
absolute. The only doubt at this period is produced by those cases 
of pregnancy with dead fetus. Under such circumstances the 
sound may be used. 

In the very large tumors of the ovary a differential diagnosis 
must be made from obesity and meteorismus. A real diagnosis 
between free ascites and ovarian tumor is often made only at opera- 
tion. It is essential to prove the pedicled connection with the 
uterus. In free ascites the abdomen is more flat, the lateral borders 
of the abdomen are prominent, and the center of the abdomen is 
more flat. Cysts produce a projection in the middle of the ab- 
domen, while the lateral borders are flatter. In ascites the per- 
cussion note in the lower part of the abdomen is dull, while it is 
tympanitic above. With increase of the ascites the horizontal line 
of delimitation between the dull area below and the tympanitic 
area above extends upward above the umbilicus until finally the 



662 MEDICAL GYNECOLOGY 

tympanitic note is entirely lost, if so much fluid is accumulated 
that the interstitial mesentery is too short to permit the intestines 
to come near the abdominal wall. Ovarian tumors produce a 
dull note in the center and a tympanitic note laterally. An im- 
portant diagnostic point is found in the fact that even if ascites 
gives a dull note on percussion, yet percussion with the fingers 
pressed deeply into the abdomen will give a touch of tympanitic 
resonance. In ascites if the hands are placed on the lateral borders 
of the abdomen and tapped gently, a wave of fluctuation toward 
the other side is produced. Alterations in tympanitic resonance are 
produced by changes of position. If tapping is done, ascitic fluid 
has a specific gravity of ioio to 1015. 

A very difficult diagnosis is that of ascites associated with ovar- 
ian tumors. When the ascites is due to papilloma, no diagnosis 
can be made without puncture and draining of the abdomen, after 
which the papillomata may be felt and disseminated nodules may 
be made out throughout the entire abdominal cavity. 

Twist 0} the pedicle in the case of ovarian cyst produces pain 
and increases the size of the tumor as the result of hemorrhage. 
There is a local peritonitis, which with gangrene of the cyst may 
become a general peritonitis. Adhesion to the intestine and omen- 
tum occurs early. 

Malignant ovarian tumors have hard irregular surfaces, are often 
double-sided, and produce ascites. Ascites is not always a sign 
of malignancy, for it may occur with glandular cystoma, with 
fibroma ovarii and fibrosarcoma of the ovary, and with papilloma. 
With malignant ovarian tumors there is cachexia, the tumor is 
firmly fixed to the surrounding structures, and hard disseminated 
nodules can be felt in the upper abdomen. 



NDEX 



Abdomen, examination, ig 
Abdominal applications for production 
of anemia and hyperemia, no 

bandage in uterine bleedings, 186 

belt in post-partum treatment, 551 

massage, 103 

supports, 108 

in constipation, 346 

walls, loose, massage in, 104 
Abel's speculum, 59 
Abortion, 564 

bleeding from, 178 

causes, 566 

curage in, 80 

curettage in, 79 

inevitable, treatment, 190 

repeated, 248 

symptoms, 569 

treatment, 571 
Abscess of Bartholin's gland, 52, 387 

ovarian, after pyosalpinx, 629 
Acetate of aluminum in leukorrhea, 

202 
Acetic acid in endometritis, 500 
Aconite in diminished excretion of urea, 

3*4. 

Adenoids, cervical, 155 

Adnexa, uterine, and appendicitis, 226 

Albargin in gonorrhea, 378 

in gonorrheal endometritis, 401 
Alcohol in neurasthenia, 317 
Aloes in constipation, 358 
Alum in leukorrhea, 203 

in metritis, 507 

in vaginitis, 449, 450 
Aluminum acetate in endocervicitis, 472 
in gonorrheal vaginitis, 391 
in vaginitis, 449 
in vulvitis, 443 
Alumnol in gonorrheal endometritis, 401 
Amenorrhea, 133 

a cause of sterility, 242 

and nervous conditions, 283 
. and onanism, 284 

diagnosis of, 140 

due to blood states, 141 

due to curettage, 147 

due to involvement of ductless glands, 
142 

due to ovarian atrophy, 142 



663 



Amenorrhea during lactation, 145 

from nervous conditions, 147 

of atresia, 138 

of castration, 144 

of chlorosis, 136 

of climacterium, 144 

of obesity, 137, 143 

of pregnancy, 145 

secondary, 141 

treatment of, 148 
Anemia by abdominal applications, 
in 

by sitz-baths, 113 

by vaginal douches, 112 

pelvic, therapeutic use, 109 
Anesthesin in pruritus, 215 
Anteflexion of uterus, 552 
Anteposition of uterus, 552 
Anteversion of uterus, 525 
Antipyrin in ovarian neuralgia, 317 
Anus, gonorrhea of, 388 
Aperients, abuse of, as a cause of con- 
stipation, 325 
Apiol, 149 
Appendicitis, relation to pelvic troubles, 

226 
Applications, intra-uterine, 66 
Applicators, urethral, 49 
Argentamin in gonorrhea, 378 

in gonorrheal endometritis, 401 

in rectal gonorrhea, 389 
Argonin in gonorrhea, 378 

in gonorrheal vaginitis, 393 
Argyrol in gonorrhea, 378 

in leukorrhea, 202 
Arhovin in gonorrhea, 375 
Arsenhemol in sterility, 253 
Arsenic in chlorosis, 313 

in neurasthenia, 317 
Arteriosclerosis of uterus, 581 
diagnosis, 583 
treatment, 584 
Ascites and tumors of ovary, differen- 
tiation, 662 

palpation, 31 
Atmocausis, technic, 82 
Atresia, amenorrhea of, 138 
Atresic follicles, 143 
Atrophic endometritis, 487 
Atrophy, lactation and subinvolution, 546 



664 



INDEX 



Atrophy of uterus, lactation, 146 
Atropin sulphate in constipation, 359 
Atypical menstruation of ectopic ges- 
tation, 645 



Bacillus tuberculosis, staining of, 44 
Backache, 234 
relief, 316 
treatment, 239 
Bacteria in vagina, 196 

of cystitis, 261 
Bacteriologic methods, 42 
Bartholinitis, gonorrheal, 386 

treatment, 388 

Bartholin's gland, abscess, 52, 387 

cyst, 388, 420 

treatment, 52 

Basedow's disease, 299 

aberrant, treatment, 321 
relative, 304 
Baths at puberty, 310 
cold, 119 
in chlorosis, 313 
in constipation, 352 
in hyperthyroidism, 321 
in metritis, 508 
in neurasthenia, 317 
in ovarian neuralgia, 316 
in parametritis, 518 
in perimetritis, 522 
in post-partum treatment, 549 
Nauheim, 122 
warm, 121 
Battery, electric, therapeutic use, 115 
Belladonna in spastic constipation, 355 
Benzoic acid in cystitis, 269 

in gonorrheal cystitis, 381 
Bichlorid of mercury in endocervicitis, 
472 
in gonorrhea of children, 368 
in gonorrheal endocervicitis, 400 
endometritis, 402 
salpingitis, 407 
vaginitis, 391, 393 
in metritis, 506, 507 
in parametritis, 507 
in pruritus, 214 
in tuberculous cystitis, 273 
in vaginitis, 449 
in vulvitis, 443 
Bierhoff's knives, 51 
Bimanual examination of uterus, 23 

massage, 10 1 
Binders, Storm, 108 
Bismuth subnitrate in vulvitis, 444 
Bivalve specula, 31 
speculum, use, 58 
Bladder, conditions outside of, as a 
cause of dysuria, 260 
examination, 37 



Bladder, hyperemia of, dysuria from, 
261 
inflammation, 261. See also Cystitis. 
irrigation of, 49 
irritable, treatment of, 272 
shrunken, 265 

treatment, 272 
stone in, 265 
treatment, 49 
tuberculosis, 265 
symptoms, 267 
treatment, 273 
tumors, 265 
Bleedings, climacteric, 577 
in endometritis, 490 
uterine, 168 
diagnosis, 180 
treatment, 181 
Blue ointment in pruritus, 214 
Blues, 288 

at puberty, 276 
Boil of vulva, 439 
Boracic solution in pruritus, 214 
Boric acid in constipation, 363 
in irritable bladder, 272 
solution in gonorrhea of children, 

3 6 9. 
Boroglycerin in endocervicitis, 471 

in leukorrhea, 205, 206 

in metritis, 507 

in urethritis, 378 
Bowels in chlorosis, care, 313 
Brandt method of massage, 101 
Braun intrauterine syringe, 65 
Brewer's speculum, 31 
Broad ligaments, palpation, 28 

varicocele, 231 
Bromids at climacterium, 320 

in coccygodynia, 221 

in endometritis, 503 

in neurasthenia, 318 

in spastic constipation, 355 

in vaginismus, 219 

in vaginitis, 449 
Bubo, inguinal 437 



Calomel ointment in pruritus, 215 

in vulvitis, 444 
Cancer of uterus. See Carcinoma of 

uterus. 
Cantharides plaster, counter-irritation 

by, 100 
Carbolic acid in cervical erosion, 472 
in chancroid, 437 
ointment in vulvitis, 444 
salve in pruritus, 214 
solution in endometritis, 503 
in gonorrheal vaginitis, 391 
in pruritus, 215 
in tuberculous cystitis, 273 



INDEX 



665 



Carbolic acid in vaginitis, 449 
Carcinoma causing bleeding, treatment 
of, 181 
cervico-uterine, 588 
of cervix, 593 

characteristics, 596 
symptoms, 597 
treatment, 600 
vaginal portion, 588 
of fundus uteri, 594 
of uterus and ectopic gestation, dif- 
ferentiation, 650 
cervical portion, 593 
characteristics, 595 
fundus, 594 
symptoms, 597 
treatment, 600 
of vagina, 588 
vulvae, 585 
Cardiac symptoms at puberty, 277 
Carlsbad salts in constipation, 361 
Cascara sagrada in constipation, 358 
Castor oil in constipation, 357 
Castration, amenorrhea from, 144 

influence, 302 
Catarrh, cervical, 451. See also Endo- 

cervicitis. 
Catarrhal endometritis, 497 
Catheterization cystitis, 263 

of ureters, 40 
Cellulitis, pelvic, 510 
acute, 510 
diagnosis, 515 
differential diagnosis, 512 
symptoms, 513 
puerperal, 511 
Cervical adenoids, 155 

catarrh, 451. See Endoceruicitis. 
Cervico-uterine gonorrhea, 394 
Cervix and tenaculum forceps, 63 
carcinoma, 593 

characteristics, 596 
symptoms, 597 
treatment, 600 
vaginal portion, 588 
dilatation, 67 

in sterility, 251, 254 
disease, sterility from, 244 
ectropion, 461 
erosions, 458 
diagnosis, 468 
origin, 459^ 

recurring, in nulliparae, 460 
treatment, 472 
hypertrophy, 464 
mobility of, determination, 28 
normal, appearance, 456 
scarification, 63 
secretion, 461 

examination, 462 
variations from normal, 457 
Chancre and carcinoma vulvae, 586 



Chancre, hard, 429 

soft, 436 
Chancroid, 436 

and carcinoma vulvae, 587 
Change of life, 300 
Chapman's water-bag, no, in 
Children, gonorrhea in, 364 
Chlorosis, amenorrhea from, 136 

bowels in, 313 

diet in, 312 

nervous symptoms in, 281 

treatment, 312 
Chorea minor and puberty, 281 
Chorio-epithelioma, 602 

bleeding from, 179 

characteristics, 603 

characteristics of growth, 607 

fetal origin, 606 

histopathology, 604 

relation of ovarian secretion to, 608 
Climacteric bleedings from fibrosis 

uteri, 577 
Climacterium, influence of, 300 

praecox, 142 

states allied to, 308 

theory, 304 

treatment, 320 
Climate and puberty, 311 
Clothing at puberty, 310 
Cocain salve in pruritus, 215 

in vulvitis, 444 
Coccygodynia, 221 
Codein in pruritus, 217 
Coitus interruptus, 314 
Cold water, therapeutic use of, 119 
Coli bacillus cultures in constipation, 

Colonic lavage in diagnosis of consti- 
pation, 33 2 
Colpitis, 445. See also Vaginitis. 
Condyloma, broad, and carcinoma 
vulvae, 586 
gonorrheal, in children, 366 
latum, 431 

pointed, and carcinoma vulvae, 586 
Constipation, 322 
diagnosis, 331 
etiology, 324 
exercise in, 335 
pathology, 327 
prognosis, 334 
prophylaxis, 334 
sequels, 331 
spastic, 354 
symptomatology, 329 
treatment, 400 

abdominal supports, 346 
diet, 337 
drugs, 356 
electricity, 347 
exercise, 339 
habit, 336 



666 



INDEX 



Constipation, treatment, hydrotherapy 

massage, 342 
postural method, 340 
suggestion, 355 
vibration, 344 
Copaiba in gonorrhea, 375 

in gonorrheal cystitis, 382 

in cystitis, 270 
Corpus luteum, cysts, 652 
Corrosive sublimate in leukorrhea, 202 
Corsets, 109 
Cotarnin hydrochlorate, 183 

phthalate, 184 
Counter-irritation, 100 
Creolin in kraurosis, 218 
Curage, 80 

in abortion, 573 
Curet in abortion, 573 

in carcinoma uteri, 600 

in diagnosis of gonorrhea, 424 
Curets, 69 
Curettage, amenorrhea from, 147 

in sterility, 251, 255, 256 

indications, 70 

of uterus, 69, 74 

technic, 74 
Curetting in myometrial degeneration, 

5 8 4 
Curettment in endometritis, 502 

Cyst, dermoid, of ovary, 655 
of Bartholin's gland, 388, 420 
of corpus luteum, 652 
of Graafian follicle, 652 
of ovary and ectopic gestation, differ- 
entiation, 650 

diagnosis, 660 

pain in, 223 

twist of pedicle, 662 
parovarian, 653 
retention of ovary, 652 
tubo-ovarian, 626, 653 
Cystic changes in ovary, 651 
Cystitis, 261 
acute, 262 

alteration of mucosa in, 262 
bacteria of, 261 
causes, 261 
chronic, 265 
diagnosis, 266 
gonorrheal, 263, 380 

histopathology, 380 

in children, 366 

symptoms, 381 

treatment, 271, 381 
idiopathic, 263 
treatment, 269 
tuberculous, 265 

symptoms, 267 

treatment, 273 
Cystocele, 556, 559 
treatment, 562 



Cystoma, glandular, of ovary, 653 

papillary, of ovary, 654 
Cystoscopes, 38, 39, 40 



Degeneration of myometrium, 576 
diagnosis, 583 
treatment, 584 
Dermatitis of vulva, 211 
Dermoid cysts of ovary, 655 
Descensus uteri, 552 
Diabetes causing pruritus, 211 
Diabetic vulvitis, 442 
Diet in chlorosis, 312 

in constipation, 337 

in neurasthenia, 319 
Digalen at climacterium, 320 
Digitalis, 184 
Dilatation of cervix, 66 

in sterility, 251, 254 
Dilators, cervical, 66, 67 
Discharge in endometritis, 493 
Displacements of uterus a cause of 
abortion, 569 

visceral, relation to neurasthenia, 287 
Douches in abortion, 572 

in constipation, 352 

in endocervicitis, 472 

in endometritis, 500 

in gonorrheal endometritis, 401 
vaginitis, 392 

in malposition of uterus, 555 

in metritis, 506, 507 

in myometrial degeneration, 584 

in parametritis, 517 

in perimetritis, 522 

in sterility, 251, 253, 255 

in vaginitis, 203 

vaginal, 52 

for pelvic anemia and hyperemia, 112 
Drugs in constipation, 356 
Dysmenorrhea, 151 

from hypoplasia, 153 

mechanical, 153 

membranacea, 156 

of endometritis, 155 

ovarian, 157 

treatment, 162 

tubal, 157 
Dyspareunia, 220 
Dysuria, 258 

causes, 258 



Ectopic pregnancy, 634 

and cancer of uterus, differentia- 
tion, 650 
and hematocele, differentiation, 644 
and ovarian cyst, differentiation, 

650 
and pyosalpinx, differentiation, 631 
and salpingitis, differentiation, 649 



INDEX 



667 



Ectopic pregnancy and uterine polyps, 
differentiation, 649 
atypical menstruation of, 645 
bleeding from, 176 
course, 639 
diagnosis, 643 
differential, 648 
early, 644 
from gonorrhea, 426 
histopathology, 638 
history, 646 
non-tragic stage, 647 
pain in, 222 
physical stage, 647 
symptoms, 642 
tragic stage, 647 
treatment, 650 
Ectropion of cervix, 461 

treatment, 474 
Eczema of vulva, 24 

treatment, 216 
Education and puberty, 311 
Electricity in constipation, 347 
in neurasthenia, 317 
in ovarian neuralgia, 317 
intrauterine, in dysmenorrhea, 117 

in sterility, 253 
therapeutic use, 115 
Electrodes, vaginal, 116, 117 
Embryo, death, 574 
Enchondroma of ovary, 656 
Endocervicitis, 451 
acute, 454 
cervical form, 458 
diagnosis, 469 
etiology, 451 
evidences, 456 
gonorrheal, 394 
leukorrhea from, 198 

treatment, 205 
subacute, 455 
symptoms, 466 
treatment, 471 
vaginal form, 458 
Endometritis, 476 

a cause of abortion, 567 

causing sterility, 245 

atrophic, 487 

bleeding from, 186, 187 

catarrhal, 497 

changes in uterine wall, 483 

deciduae, 498 

dysmenorrhceica, 498 

etiology, 476 

fungosa, 494 

glandular, 483 

changes in, 483 
gonorrheal, 394, 496 
diagnosis, 397 
symptoms, 397 
treatment, 400 
hyperplastic, treatment, 502 



Endometritis, inflammatory, 481 
use of curet in, 71 

interstitial changes, 483 

laboratory findings, 486 

leukorrhea from, treatment, 208 

membranacea, treatment, 503 

non-inflammatory, 479 

objective signs of, 494 

sapremic. treatment, 500 

senile, 498 

treatment, 503 

septic, 496 

treatment, 500 

sequels, 499 

symptoms, 490 

treatment, 500 

varieties, 494 
Endometrium, disease of, causing ster- 
ility, 244 

gonorrheal involvement, 504 

hyperesthesia of, 160 

inflammation of, bleeding from, 170 

sapremic, 495 

structure of, 476 
Enema in constipation, 362 
Enterocele, 561 
Epilepsy and puberty, 280 
Epsom salts in constipation, 360 
Ergot, 183 

in abortion, 571 

in endometritis, 500, 502 
Ergotin, 183 

at climacterium, 321 

in metritis, 508 
Ergotol, 183 

in abortion, 571 

in metritis, 506, 508 

in post-partum treatment, 549 
Erosions, leukorrhea from, 198 
treatment, 205 

of cervix, 458 

and gonorrhea, 423 
diagnosis, 468 
meaning, in nulliparae, 460 
origin, 459 
treatment, 472 
Eucain in pruritus, 214 
Examination, 17 

by specula, 31 

of abdomen, 19 

of bladder, 37 

of rectum, 42 

of ureter, 40 

of urethra, 37 

of uterus, 23 

of vagina, 21 

of vulva, 21 
Examining table, 20 
Exercise at puberty, 310 

in constipation, 335, 339 

in post-partum treatment, 550 
Exodin in constipation, 360 



668 



INDEX 



Fallopian tubes, diseases of, causing 
sterility, 245 
gonorrhea, 405 
inflammation, 620 
tuberculosis, 631 
Faradic current, use of, 118 
Feces, sources, 322 

Ferguson's speculum in vaginitis, 203, 
205 
use, S3 
Ferratin in chlorosis, 313 
Fibromyoma of uterus, 610 
bleeding from, 180 

treatment, 189 
diagnosis, 613 
palpation of, 30 

pregnancy and, differentiation, 614 
sequels, 615 
symptoms, 612 
treatment, 618 
Fibrosis of uterus, 576 
bleeding from, 180 
diagnosis, 583 
treatment, 584 
Finger's treatment in gonorrhea, 379 
in gonorrheal cystitis, 383 
vaginitis, 392 
Flexion of uterus, 525 
Follicle, Graafian, cysts of, 652 

of Naboth, 470 
Formulae for amenorrhea, 148 
for chancroid, 437 
for chlorosis, 313, 314 
for climacterium, 321 
for constipation, 357 
for dysmenorrhea, 162-167 
for gonorrhea, 379 
in children, 369 
for gonorrheal cystitis, 381 
for leukorrhea, 202-208 
for neurasthenia, 318 
for pruritus vulvas, 215, 216, 217 
for syphilis, 43°> 43 2 > 434, 435 
for uterine bleeding, 184, 188 
Fowler's solution in chlorosis, 313 
Fritsch-Bozeman irrigator. 68 
Fundus uteri, carcinoma, 594 
mobility, determination, 27 
Furunculosis vulvar-, 439 



Galvanic current, therapeutic use, 115 

Garrigues' weighted speculum, 59 

Giemsa's stain, 46 

Glandular changes in endometritis, 483 
cystoma of ovary, 653 

Glauber's salts in constipation, 360 

Gle*nard's disease, relation to neur- 
asthenia, 287 

Glonoin at climacterium, 320 

Glycerin in constipation, 362 
in endocervicitis, 472 



Glycerin in endometritis, 503 

in gonorrhea, 378 

in gonorrheal endometritis, 401 

in leukorrhea, 208 

in malposition of uterus, 555 

in metritis, 507 

in parametritis, 517 

in sterility from salpingitis, 255 
Glycerophosphates in neurasthenia, 318 
Gonococcus, changes produced by, 413 

characteristics, 410 

cultures for, 45 

difference from pus-producing cocci, 

415. 
extension, 412 

in gonorrhea of children, 365 
infection. See Gonorrhea. 
mixed infection, 411 
relation, to infected tissue, 409 

pregnancy, 414 
staining, 43 
virulence, 428 
Gonorrhea, anal, 419 

cervical, treatment of, 207 
cervico-uterine, 394 
characteristics, 409 
course, 426 

curet in diagnosis, 424 
ectopic gestation and, 426 
in adults, 371 

diagnosis, 374 

symptoms, 373 

treatment, 375 
in children, 364 

etiology, 364 

histopathology, 365 

rectum and anus, 366 

treatment, 368 

constitutional, 370 
in male, 416 
latent, 398, 417 

clinical diagnosis, 423 
marriage and, 417 
of anus, 388 
of ovaries, 405 
of peritoneum, 405 
of rectum, 388, 419 

in children, treatment, 369 
of tubes, 405 
sterility from, 425 
unrecognized, 417 
virulence, 413 

with no clinical symptoms, 399 
Gonorrheal bartholinitis, 386 
cystitis, 263, 380 

treatment of, 271 
endometritis, 394, 496 
metritis, 504 
peritonitis, latent, 419 
salpingitis, 405 
vaginitis, 389 
vulvitis, 385 



INDEX 



669 



Gonosan in cystitis, 270 

in gonorrhea, 376 
Graafian follicle, cysts of, 652 
Gram stain for gonococci, 43 
Graves' disease, 299 

speculum, 31 
Gumma, 432 
Gymnastics in constipation, 335, 340 

in post-partum treatment, 550 
Gynecologic examination, 17 



Habit in treatment of constipation, 336 
Habits, effect in constipation, 324 
Habitual constipation, 322 
Hard chancre, 429 
Headache, relief, 316 
Hegar's dilators, 68 

sign, determining, 565 
Helmitol in cystitis, 269 

in gonorrheal cystitis, 381 
Hematocele and ectopic gestation differ- 
entiation, 644 

and pyosalpinx, differentiation, 631 
Hemorrhages, climacteric, 577 

uterine, from myometrial degenera- 
tion, 576 
Heredity, influence at puberty, 279 
Hernia, vaginal, 556 

treatment, 562 
Heroin at climacterium, 320 
History taking, 18 
Hodge pessary, 89 

Houston's valves in constipation, 332 
Hydrastinin at climacterium, 321 

hydrochlorate, 508 
Hydrastis, 183 

in endometritis, 502 
Hydrosalpinx, 625 
Hydrotherapy, 119, 132 

at puberty, 310 

in constipation, 351 

in sterility, 255 
Hygiene of puberty, 309 
Hyoscin at climacterium, 320 

hydrobromate in endometritis, 503 
Hyoscyamus in constipation, 359 

in cystitis, 270 
Hyperemia by abdominal applications, 
in 

by sitz-baths, 113 

by vaginal douches, 113 

of bladder mucosa, dysuria from, 261 

pelvic, therapeutic use of, 109 
Hyperesthesia of the endometrium, 160 
Hyperplasia of endometrium, 495 
Hypersecretion, vaginal, 196 
Hyperthyroidism, 309 

and subinvolution, 547 

treatment, 321 
Hypertrophy of cervix, 464 
Hypoplasia of uterus, 135 



Hypoplasia of uterus, causing sterility, 

243 
treatment, 253 

Hysterectomy in myometrial degenera- 
tion, 584 

Hysteria, 289 

and parametritis atrophicans, 295 
and puberty, 280 
reflex, 295 

Hysterical symptoms, 289' 

Hysteroptosis, 544, 552 
treatment, 554 



Ichthargan in gonorrhea, 378 

in gonorrheal endometritis, 402 
Ichthyol in cystitis, 271 

in irritable bladder, 272 

in leukorrhea, 207 

irrigation in gonorrheal cystitis, 383 

in vaginitis, 449 
Idiopathic cystitis, 263 
Inevitable abortion, treatment of, 190 
Inflammation of Fallopian tubes, 620 
Inflammatory conditions, reflex neuroses 

from, 294 
Inguinal bubo, 437 
Injections, uterine, 65 
Inspection of vulva, 21 
Interstitial oophoritis, 651 
Intertrigo of vulva, 211 
Intrauterine applications, 66 

pessary, 98 

>vringe, 65 

therapy, 64 
Iodin in cervical erosions, 473 

in chancroid, 437 

in endocervicitis, 472 

in endometritis, 502, 503 

in gonorrhea, 377 

in gonorrheal endometritis, 402 
vaginitis, 392 

in sterility, 254 

from salpingitis, 255 

tincture, in leukorrhea, 202 
in pruritus, 214 
Iodoform in endometritis, 503 
Iron in chlorosis, 313 
Irrigation in cystitis, 271 

in gonorrhea of children, 368 

in gonorrheal cystitis, 382 

of bladder, 49 

of urethra, 49 

uterine, 68 
Irritable bladder, treatment, 272 



Jenner's stain for gonococci, 43 

Kava-kaya in cystitis, 270 
in gonorrhea, 376 
in gonorrheal cystitis, 382 



670 



INDEX 



Kinesiotherapy in constipation, 339 
Kneading in massage, 104, 105 
Kraurosis vulvae, 212, 442 
treatment, 218 



Lactation atrophy and subinvolution, 
546 
of uterus, 146 
Lactic acid and bacilli in constipation, 

362 
Laparotomy, massage after, 104 
Largin in gonorrhea, 377 

in gonorrheal endometritis, 401 
vaginitis, 393 
Latent gonorrhea, 398 
Lateroposition of uterus, 552 
Lateroversion of uterus, 525 
Lavage of colon in diagnosis of constipa- 
tion, 332 
Lavedan's cup pessary, 98 
Lead acetate in gonorrhea, 378 
Leukoplakia of vulva, 585 
Leukorrhea, 195 

causing pruritus, 213 

from colpitis, 197 

from endocervicitis, 198 

from erosions, 198 

from uterus, 199 

of virgins, 203 

treatment, 201 
Liquor plumbi acetatis in vulvitis, 442 
Lugol's solution, 44 

in endometritis, 503 
in vaginitis, 449 
Lymphadenitis syphiliticum, 430 
Lysol in endometritis, 500, 503 

in metritis, 506, 507 

in parametritis, 517 

in pruritus, 214 



Magnesium sulphate in constipation, 

361 
Malignant tumors of ovary, 662 
Malposition of uterus, 552 
Massage, abdominal, 103 

in constipation, 342 

in malposition of uterus, 555 

in post-partum treatment, 548 

of urethra, 37, 38 

vagino-abdominal, 101 
Masturbation. See Onanism. 
Maternal tissues, changes in, a cause of 

abortion, 567 
Membranous endometritis, 499 
Menge pessary, 97 
Menopause, artificial, 302 

nervous conditions in, 300 

states allied to, 308 

theory, 304 

treatment, 320 



Menorrhagia, 169 

and masturbation, 284 

Menstruation, absence, 133 
at puberty, care during, 312 
atypical, of ectopic gestation, 645 
beginning, 275 
effect of onanism on, 284 
nervous symptoms during, 282 
painful, 151 
vicarious, 138 

Mental influences in causation of con- 
stipation, 327 

Menthol ointment in pruritus, 215 
in vulvitis, 444 

Mercurial ointment in syphilis, 434 

Methyl blue in cystitis, 259 
in gonorrheal cystitis, 381 

Metritis, 504 

gonorrheal, 394, 504 
treatment, 506 

Metro-endometritis, pain of, 224 

Metrorrhagia, 168, 175 
diagnosis, 180 
treatment, 181 

Microclysters, 362 

Microscope in diagnosis of latent gonor- 
rhea, 422 

Micturition, frequent, 258 
causes of, 258 

Migraine and puberty, 281 

Mixed tumors of ovary, 656 

Molimina menstrualia, 141 

Morphin in cystitis, 270 

Mustard plaster, 101 

Myometrium, degeneration, 576 
diagnosis, 583 
treatment, 584 



Naboth, follicles of, 470 

ovula of, 463 
Nauheim bath, 122 

in chlorosis, 313 

in metritis, 509 

in parametritis, 518 

in perimetritis, 522 

in post-partum treatment, 549 

in retroflexion, 540 

in retroversion, 539 

in sterility, 253, 256 
Neptune's girdle in constipation, 353 
Nervous conditions, amenorrhea from, 

147 

in gynecology, 275 

treatment, 317 
disorders of climacterium, 300 
symptoms and castration, 302 

and onanism, 283 

and splanchnoptosis, 287 

at puberty, 276 

during menstruation, 282 

in chlorosis, 281 



INDEX 



671 



Nervous symptoms in pregnancy, 286 
Neuralgia, ovarian, 160 

treatment, 316 
Neurasthenia, 291 

and menopause, 301 

relation of ptoses to, 287 

splanchnic, 288, 545 

treatment, 317 
Neuroses at puberty, 280 

reflex, 293 
New growths, bleeding from, 1 75 
Nitrate of silver in pruritus, 217 
Nitroglycerin in diminished urea ex- 
cretion, 314 
Nourishment, importance at puberty, 

310 
Nux vomica in constipation, 359 



Obesity, amenorrhea of, 137, 143 
(Edema indurativum, 429 
Oil enema in constipation, 362 
in spastic constipation, 355 
Onanism, a cause of nervous svmptoms, 

283 
of vulvitis, 440 
pruritus from, 211 
treatment, 314 
One-child sterility, 247 
Oophoritis, chronic, diagnosis, 659 
interstitial, 651 
pain in, 232 
Opium in cystitis, 269 
Osteoma of ovary, 656 
Otis cystoscope, 39 
Ova, defect of, causing sterility, 243 
Ovarian abscess after pyosalpinx, 629 
cyst and ectopic gestation, differen- 
tiation, 650 
pain in, 223 
palpation, 30 
dysmenorrhea, 157 
neuralgia, 160 

treatment, 316 
secretion, relation to chorioepithe- 
lioma, 608 
Ovarin, 148, 162 

at climacterium, 320 
in Basedow's disease, 321 
in chlorosis, 313 
in climacterium, 321 
in endometritis, 503 
in sterility, 253 
Ovary, changes in, at puberty, 275 
cystic changes in, 651 
cysts, diagnosis, 660 

twist of pedicle, 662 
dermoid cysts, 655 
diseases, 651 

diagnosis, 659 
enchondroma, 6c6 



glandular cystoma, 653 



Ovary, gonorrhea, 405 

mixed tumors, 656 

osteoma, 656 

papillary cystoma, 654 

proliferating tumors, 653 

retention cysts, 652 

solid tumors, 659 

teratoma, 656 

tumors, and ascites, differentiation, 
662 
diagnosis, 660, 661 
malignant, 662 
Overfeeding in neurasthenia, 318 
Ovoferrin in chlorosis, 313 
Ovula of Naboth, 463 
Ovulation, 133 
Ovum, abnormalities of, 566 

changes in, a cause of abortion, 566 

embedding, 655 



Pain, 219 

in appendicitis, 226 

in cystitis, 267 

in ectopic gestation, 222 

in endometritis, 492 

in metro-endometritis, 224 

in nervous conditions, relief of, 316 

in oophoritis, 232 

in ovarian cyst, 223 

in parametritis, 225 

in pregnancy, 234 

in salpingo-oophoritis, 226 

in varicocele, 231 

pelvic, significance, 219, 221 

right-sided, significance, 234 

treatment, 236 
Papillary cystoma of ovary, 654 
Parametritis, 510 

acute, 510 

and gonorrhea, 424 

atrophicans and hysteria, 295 
diffuse, 515 

bleeding from, 185 

diagnosis, 515 
differential, 512 

in cervical catarrh, 466 

pain in, 225 

puerperal, 511 

retrahens, 515 

subacute, 514 

treatment, 516 
Parametrium, palpation, 28 

stretching, by massage, 102 
by pressure, 98 
Pararegulin in constipation, 362 
Parovarian cysts, 653 
Pelvic anemia, therapeutic use of, 109 

cellulitis, 510 

counter-irritation in, 100 
diagnosis, 515 
symptoms, 513 



6 7 2 



INDEX 



Pelvic hyperemia, production, 109 

inflammation, 10. See also Pelvic 

Cellulitis. 
pain, significance, 221 

treatment, 236 
peritonitis, 519 
diagnosis,52i 
pain in, 225 
treatment, 521 
subinvolution, 543 
Pelveoperitonitis, 520 
Pericystic conditions, dysuria from, 260 
Perimetritis, 519 
diagnosis, 521 
treatment, 521 
Perioophoritis, 520 
Peritoneum, gonorrhea, 405 
Peritonitis, gonorrhea, latent, 419 
pelvic, 519 
diagnosis, 521 
pain in, 225 
treatment, 521 
Peri-uterine inflammation, bleeding from, 

169 
Pessaries, 89 
Pessary in cystocele, 562 
in hysteroptosis, 555 
in retrodeviations, 539 
in sterility, 253, 254 
introduction, 93 
Physostigmin salicylate in constipation, 

.359 . 
Picric acid in gonorrheal endometritis, 

402 
Pilocarpin in pruritus, 217 
Placenta, retention, 574 
Podophyllin in constipation, 359 
Polyps, treatment, 182 

uterine, and ectopic gestation, differ- 
entiation, 649 
Position, Sims, 57 

Post-partum treatment in subinvolution, 
548 
relation, to retrodeviations, 535 
Postural treatment of constipation, 340 
Potassium citrate in cystitis, 270 
iodid in endometritis, 503 
permanganate in cystitis, 271 
in gonorrheal vaginitis, 391 
in leukorrhea, 202 
in vaginitis, 449 
Powder-blower, 63 
Powders, application, to vagina, 63 
Pregnancy, 564 

and fibromyoma of uterus, differen- 
tiation, 614 
and retrodeviation of uterus, 533 
diagnosis, early, 564 
ectopic, 634 

and cancer of uterus, differentia- 
tion, 650 
and hematocele, differentiation, 644 



Pregnancy, ectopic, and ovarian cyst, 

differentiation, 650 

and pyosalpinx, differentiation, 631 

and salpingitis, differentiation, 649 

and uterine polyps, differentiation, 

649 
atypical menstruation of, 645 
bleeding from, 176 
course, 639 
diagnosis, 643 
differential, 648 
early, 644 
histopathology, 638 
history, 646 
non-tragic stage, 647 
pain in, 222 
physical stage, 647 
symptoms, 642 
tragic stage, 647 
'treatment, 650 
nervous symptoms, 286 
pain in, 234 

relation of gonococci to, 414 
Premenstrual symptoms of endometritis; 

493 
treatment, 503 
Pressure therapy, 98 
Priessnitz compress in constipation, 353 
in gonorrheal endometritis, 400 
in metritis, 508 
in pelvic peritonitis, 522 
Prolapse of uterus, 552 
pessary for, 97 

relation of retrodeviation to, 533 
erf vagina, 553 
Proliferating ovarian tumors, 653 
Protargol in cystitis, 271 
in gonorrhea, 376 
of children, 368 
in gonorrheal cystitis, 382 

endometritis, 401, 402 
in rectal gonorrhea, 389 
in vaginitis, 449 
Pruritus vulvae, 210 
treatment, 214 
Psoriasis vulvae, 585 
Psychic treatment in constipation, 355 

in nervous states, 320 
Psychoses at puberty, 280 
Psychotherapy in constipation, 355 
Ptoses, relation to neurasthenia, 287 
Puberty and hysteria, 280 
cardiac symptoms at, 277 
clothing at, 310 
constitutional changes at, 275 
education at, 311 
epilepsy at, 280 
exercise at, 310 
hydrotherapy at, 310 
hygiene of, 309 
influence of heredity in, 279 
of psychic stimuli at, 278 



INDEX 



673 



Puberty, nervous symptoms at, 276 

neuroses at, 280 

nourishment at, 310 

sleep at, 310 
Puerperal cellulitis, 511 

infection in endometritis, 478 
Purgatin in constipation, 359 
Purgatives, abuse of, as a cause of con- 
stipation, 325 
Purgen in constipation, 360 
Purulent urine, 266 
Pyosalpinx, 626 

and ectopic gestation, differentiation, 
631 

and hematocele, differentiation, 631 

bleeding from, 185 

diagnosis, 630 

etiology, 626 

gonorrheal, 406 

histopathology, 627 

ovarian abscess after, 629 

symptoms, 630 
Pyroligneous acid in erosions, 473 
in leukorrhea, 208 
in vaginitis, 4.19 



Quixin and iron in neurasthenia, 317 



Rectal bougies in constipation, 363 

medication in constipation, 362 
Rectocele, 556, 561 
Rectum, examination, 42 
gonorrhea, 388 

in children, treatment, 369 
Reflex hysteria, 295 

neuroses, 293 
Regulin in constipation, 362 
Repeated abortion, 248 
Resorcin solution in cystitis, 271 
Rest in treatment of pelvic pain, 237 
Rest-cure in neurasthenia, 319 
Retention cysts of ovary, 652 
Retractors, vaginal, 74 
Retrodeviation of uterus, 524, 525, 526 

congenital, 526 

correction by pessary, 91 

diagnosis, 536 

dignity of, 530 

frequency, 531 

menorrhagia from, 185 

pain of, treatment, 239 

relation to pregnancy, 533 

replacing uterus in, 91 

treatment, 540 
sterility from, treatment, 254 

symptoms, 529 

treatment, 538, 539 
Retrodisplacement of uterus, 552 

correction by pessary, 91 

treatment, 554 
43 



Retroflexion of uterus. See also Retro- 
deviation. 
Retroposition of uterus, 552 

treatment, 555 
Retroversio-flexio uteri, 524. See also 

Retrodeviation of uterus. 
Retroversion of uterus. See also Retro- 
deviation 0} uterus. 
Rhubarb in constipation, 357 
Right-sided pain, significance of, 234 
Rochelle salt in constipation, 360 
Rose's straps in constipation, 347 
Rupture, tubal, pain in, 223 



Salicylic acid, 149 
in cystitis, 269 

solution in cystitis, 271 
in gonorrheal cystitis, 383 
Saliformin in cystitis, 269 

in gonorrheal cystitis, 381 
Salol in cystitis, 269 

in gonorrheal cystitis, 381 
Salpingitis, 620 

and ectopic gestation, differentiation, 
649 

as cause of sterility, 245, 246, 247 

bleeding from, 185 

diagnosis, 622 

etiology, 620 

gonorrhea], 405 
treatment, 407 

histopathology, 622 

isthmica nodosa, 632 

pain in, 226 

sequels, 623 

sterility from, treatment, 255 

tubercular, 631 
Salpingo-oophoritis, 620. See also Sal- 
pingitis. 
Salt solution in gonorrheal cystitis, 382 
Sapremic endometritis, 495 
Sarcoma causing bleeding, treatment, 

181 
Scarification of cervix and uterus, 63 
Schultze tampon, 32 
Scotch douche in constipation, 353 
Secretion, examination, by tampons, 32 

obtained by suction, ^t, 

of cervix, 461 
examination, 462 

vaginal, collection, 22 
Senile endometritis, 498 

uterus, 578 
Senna in constipation, 358 
Septic endometritis, 496 
Sextonol at climacterium, 320 
Sexual instinct at puberty, 278 
Shrunken bladder, 265 
Silver in chronic cystitis, 272 

in gonorrhea of children, 368 

in gonorrheal cystitis, 383 



674 



INDEX 



Silver nitrate in cystitis, 271 
in endocervicitis, 473 
in gonorrhea, 376 
in gonorrheal endometritis, 403 
in leukorrhea, 207 
in vaginitis, 449 
in vulvitis, 443 

Sims position, 57 
speculum, use of, 57 

Sitz-baths in metritis, 508 

in pelvic anemia and hyperemia, 113 

Skene's glands, treatment of, 51 
pessary, 96 

Sleep at puberty, 310 

Smears, fixing, 42 

Smith pessary, 89 

Social conditions, effect of, 298 

Sodium glycerophosphate in climac- 
terium, 321 

Soft chancre, 436 

Sounds, dilatation of cervix by, 67 
uterine, use of, 34 

Spastic constipation, 354 

Specula, examination by, 31 
vaginal, 75, 76 

Speculum, Abel's, 59 
bivalve, use of, 58 
Ferguson's, use of, 53 
Garrigues', 59 
Sims, use of, 57 

Spermatozoa, defect of, causing sterility, 
242 
obstruction to progress of, 243 

Spirochaeta pallida, staining, 46 

Splanchnic neurasthenia, 288, 545 

Splanchnoptosis, relation to neurasthe- 
nia, 287 

Staining for gonococcus, 43 
of spirochaeta pallida, 46 

Stenosis of cervix, sterility from, treat- 
ment of, 254 

Sterility, 241 

acquired, causes, 246 
and gonorrhea, 425 
congenital, causes, 246 
from amenorrhea, 242 
from cervical disease, 244 
from defect of ova, 242 
of spermatozoa, 242 
from endometrial disease, 245 
from hypoplasia of uterus, 243 

treatment, 253 
from obstruction to spermatozoa, 243 
from ovarian disease, 246 
from retroflexion, treatment, 254 
from salpingitis, treatment of, 255 
from stenosis of cervix, treatment of, 

254 
from tubal disease, 245 
one-child, 247 
primary, 248 
secondary, 250 



Sterility, treatment, 250 
Stone in bladder, 265 
Storm binder, 108 

in constipation, 346 
Strontium bromid at climacterium, 321 
Strychnin at climacterium, 320 

in constipation, 359 

in neurasthenia, 318 
Stypticin, 183 

at climacterium, 321 

in endometritis, 502 

in metritis, 508 
Styptol, 184 
Subinvolution, 541 

bleeding from, 187 

constitutional, 544 

fibrosis, 542 

pelvic, 543 

prophylaxis, 548 

simple, 541 
Suggestion in constipation, 355 
Sulphur in constipation, 359 
Suprarenal extract, 184 
Syphilis, 429 

and carcinoma vulvae, 588 

treatment, 433 



Table for examinations, 20 
Tampon, Schultze, 32 
Tampons, 59 

Tannic acid in leukorrhea, 203 
in metritis, 507 
in vaginitis, 450 
Tenaculum forceps, 63 
Tenesmus vesicae, 258 
Teratoma of ovary, 656 
Thomas pessary, 89 
Thymol in vaginitis, 449 
Thyraden, 184 
Thyroid extract, 184 

effect of administration, 306 

relation to reproductive function, 304 
Tilden Brown cystoscope, 39, 40 
Training of young girls, 278, 279 
Trigonitis, 264 

treatment, 272 
Tubal dysmenorrhea, 157 

rupture, pain in, 223 
Tubercular salpingitis, 631 
Tuberculosis bacilli, staining of, 44 

inoculation of guinea-pigs for, 46 

of adnexa and appendicitis, 229 

of bladder, 265 
symptoms, 267 
treatment, 273 

of Fallopian tubes, 631 
Tuberculous cystitis, treatment, 273 
Tubo-ovarian cysts, 626, 653 
Tumors of bladder, 265 

of ovary and ascites, differentiation, 
662 



INDEX 



675 



Tumors of ovary, diagnosis, 660, 661 

malignant, 662 

mixed, 656 

proliferating, 653 

solid, 659 
of urethra, as cause of dysuria, 260 
Tupelo tents for dilating the cervix, 66 



Ulcus molle, 436 

rodens vulvae and carcinoma, 587 
Urea, diminished excretion of, and 
nervous symptoms, 289 
treatment, 314 
Ureters, catheterization, 40 

examination, 40 
Urethra examination of, 21, 37 
glands of, treatment, 51 
irrigation, 49 
massage, 37, 38 
treating of, 48 
Urethral applicators, 49 
Urethritis and latent gonorrhea, 418 
as cause of dysuria, 258 
gonorrheal, 371 
diagnosis, 374 
in children, 366 
symptoms, 373 
treatment, 375 
Urination, frequent, 258 
Urine, abnormal, causing pruritus, 211 
bacteriologic cultures from, 45 
microscopic examination, 44 
purulent, 266 
Urotropin in cystitis, 269 
in gonorrhea, 375 
in gonorrheal cystitis, 381 
in irritable bladder, 272 
in pruritus, 214 
Uterine bleedings, 168 
diagnosis, 180 
treatment, 181 
hypoplasia, 135 

polyps and ectopic gestation, differ- 
entiation, 649 
sound, use of, 34 

wall, change in, bleeding from, 170 
in endometritis, 483 
Uterosacral ligaments, palpation, 28 

stretching, 10 1 
Uterus, anteflexion, 525 
anteposition, 552 
ante version, 525 
applications to, 66 
arteriosclerosis, 581 
diagnosis, 583 
treatment, 584 
carcinoma of, and ectopic gestation, 
differentiation, 650 
cervical portion, 593 
characteristics, 595 
fundus, 594 



Uterus, carcinoma of, symptoms, 597 

treatment, 600 
changes in, as cause of abortion, 568 
chorio-epithelioma, 602 
curets for, 69 
descensus, 552 
descent, 543 

displacements, a cause of abortion, 569 
elastic fibers, 579 
enlarged, bleeding from, 172 
examination, 23 
fibromyoma, 576, 610 

bleeding from, 180 
treatment, 189 

diagnosis, 613 

palpation, 30 

pregnancy and, differentiation, 614 

sequels, 615 

symptoms, 612 

treatment, 618 
fibrosis, 576 

diagnosis, 583 

treatment, 584 
flexion, 525 
gonorrhea, 394 

diagnosis, 397 

treatment, 400 
hypoplasia, causing sterility, 243 
inflammation, 504. See Metritis and 

Endometritis. 
injections into, 65 
irrigation, 68 
lateroposition, 552 
lateroversion, 525 
malposition, 552 
prolapse, 552 

pessary for, 97 

relation of retrodeviation to, 533 
ptosis, 552 
retrodeviations, 524 

congenital, 526 

diagnosis, 536 

frequency, 531 

symptoms, 529 

treatment, 538 
retrodisplacement, 552 
retroflexion, 525, 526 

treatment, 540 
retroposition, 552 
retroversion, 525, 526 

treatment, 539 
scarification, 63 
senile, 578 

subinvolution, 541. See also Sub- 
involution. 
treatment, 64 
Uva ursi in cystitis, 270 

in gonorrheal cystitis, 382 



Vagina and bladder, anatomic rela- 
tions, 557 



676 



INDEX 



Vagina, bacteria in, 196 

carcinoma, 588 

hypersecretion from, 446 

inspection, 21 

malposition, 552 

prolapse, 553 

treatment, 52 
Vaginal douche. See Douche. 

electrodes, 116, 117 

hernia, 556 
treatment, 562 

massage, 10 1 

secretions, collection, 22 
normal, 195 

tampons, 59 
Vaginismus, 219 

treatment, 219 
Vaginitis, 445 

acute, 446 

chronic, 447 

diagnosis, 448 

douches in, 203 

emphysematosa, 448 

etiology, 445 

gonorrheal, 389 
primary, 391 
secondary, 390 
symptoms, 390 
treatment, 391 

granulosa, treatment, 392, 450 

leukorrhea from, 197 
treatment, 202 

mycotica, 447 

senile, 447 

treatment, 450 

treatment, 449 
Vagino-abdominal massage, 101 
Vaginofixation in cystocele, 562 

in hysteroptosis, 555 
Vaginosuspension in cystocele, 562 
Varicocele, pain in, 231 
Version of uterus, 425 



Vibration in constipation, 344 
Viburnum prunifolium in abortion, 575 
Vicarious menstruation, 138 
Volsella, 63 
Vulva, carcinoma, 585 

glands of, treatment, 51 

inspection, 21 

leukoplakia, 585 

pruritus, 210 

psoriasis, 585 
Vulvitis, 439 

catarrhal, 440 

chronic, 441 

diabetic, 442 

gonorrheal, 385 
treatment, 386 

leukorrhea from, treatment, 201 

pruriginosa, 212, 441 

pruritus from, 212 

treatment, 442 
Vulvovaginitis, gonorrheal, in children,, 

364, 421 



Warm baths, active, 121 
Water bag, no, in 

cold, therapeutic use, 119 



Yeast in constipation, 362 



Zinc chlorid in cervical erosion, 473 
in endometritis, 502, 503 
in gonorrheal endometritis, 403 
in leukorrhea, 207 
ointment in vulvitis, 443 
sulphate in endocervicitis, 472 
in gonorrhea, 378 
in metritis, 507 
in vaginitis, 450 
valerianate in neurasthenia, 317 



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fessor of Pathology and Bacteriology in the Medico-Chirurgical Col- 
lege of Philadelphia. Octavo of 818 pages, with 350 illustrations, 
many in colors. Cloth, $5.00 net; Half Morocco, £6.50 net. 

RECENTLY ISSUED— BEAUTIFULLY ILLUSTRATED 

Unlike most works on pathology, this work treats the subject, not from the 
professor' s point of view, but from that of the student. The text is admirably- 
elucidated by numerous excellent illustrations, many of them having been especi- 
ally drawn. 

American Medicine 

" We feel confident in saying no other recent treatise, not encyclopedic in character on any 
subject, contains so much direct and correlated information on the branch with which it deals." 



SAUNDERS' BOOKS ON 



Dtirck and Hektoen's 

General Pathologic Histology 



Atlas and Epitome of General Pathologic Histology. By Pr. 

Dr. H. Durck, of Munich. Edited, with additions, by Ludvig Hek- 
toen, M. D., Professor of Pathology in Rush Medical College, Chicago. 
172 colored figures on JJ lithographic plates, 36 text-cuts, many in 
colors, and 353 pages. Cloth, $5 .00 net. In Saunders 1 Hand- Atlas Series. 

A NEW VOLUME— RECENTLY ISSUED 

This new Atlas will be found even more valuable than the two preceding 
volumes on Special Pathologic Histology, to which, in a manner, it is a com- 
panion work. The text gives the generally accepted views in regard to the signifi- 
cance of pathologic processes, explained in clear and easily understood language. 
The lithographs in some cases required as many as twenty-six colors to reproduce 
the original painting. Dr. Hektoen has made many additions of great value. 

W. T. Councilman, M. D., 

Professor of Pathologic Anatomy, Harvard University. 

" I have seen no plates which impress me as so truly representing histologic appearances 
as do these. The book is a valuable one." 

Howell's Physiology 



A Text=Book of Physiology. By William H. Howell, Ph.D., 
M. D., Professor of Physiology in the Johns Hopkins University, Balti- 
more, Md. Octavo of 915 pages, 275 illustrations. Cloth, $4.00 net. 

RECENTLY ISSUED— NEW (2d) EDITION 

Dr. Howell has had many years of experience as a teacher of physiology in 
several of the leading medical schools, and is therefore exceedingly well fitted to 
write a text-book on this subject. Main emphasis has been laid upon those facts 
and views which will be directly helpful in the practical branches of medicine. At 
the same time, however, sufficient consideration has been given to the experimen- 
tal side of the science. The entire literature of physiology has been thoroughly 
digested by Dr. Howell, and the important views and conclusions introduced into 
his work. Illustrations have been most freely used. 

The Lancet, London 

" This is one of the best recent text-books on physiology, and we warmly commend it to the 
attention of students who desire to obtain by reading a general, all-round, yet concise survey of 
the scope, facts, theories, and speculations that make up its subject matter." 



PATHOLOGY. 



Stengel's 
Text-Book of Pathology 

Recently Issued— The New (5th) Edition 



A Text=Book of Pathology. By Alfred Stengel, M. D., Professor 
of Clinical Medicine in the University of Pennsylvania. Octavo volume 
of 979 pages, with 400 text-illustrations, many in colors, and 7 full-page 
colored plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.50 net. 

WITH 400 TEXT-CUTS, MANY IN COLORS, AND 7 COLORED PLATES 

In this work the practical application of pathologic facts to clinical medicine 
is considered more fully than is customary in works on pathology. While the 
subject of pathology is treated in the broadest way consistent with the size of the 
book, an effort has been made to present the subject from the point of view of the 
clinician. In the second part of the work the pathology of individual organs and 
tissues is treated systematically and quite fully under subheadings that clearly 
indicate the subject-matter to be found on each page. In this edition the section 
dealing with General Pathology has been most extensively revised, several of the 
important chapters having been practically rewritten. A very useful addition 
is an Appendix treating of th' technic of pathologic methods, giving briefly the 
most important methods at present in use for the study of pathology, including, 
however, only those methods capable of giving satisfactory results. The book 
will be found to maintain fully its popularity. 



PERSONAL AND PRESS OPINIONS 



William H. Welch, M. D., 

Professor of Pathology, Johns Hopkins University, Baltimore, Aid. 

" I consider the work abreast of modern pathology, and useful to both students and practi- 
tioners. It presents in a concise and well-considered form the essential facts of general and 
special pathologic anatomy, with more than usual emphasis upon pathologic physiology." 

Ludvig Hektoen, M. D., 

Professor of Pathology, Rush Medical College, Chicago. 

" I regard it as the most serviceable text-book for students on this subject yet written by an 
American author." 

The Lancet, London 

"This volume is intended to present the subject of pathology in as practical a form as pos- 
sible, and more especially from the point of view of the 'clinical pathologist.' These subjects 
have been faithfully carried out, and a valuable text-book is the result. We can most favorably 
recommend it to our readers as a thoroughly practical work on clinical pathology." 



SAUNDERS 1 BOOKS ON 



the best /\ m e r i c a n standard 
Illustrated Dictionary 

Recently Issued— New (4th) Edition 



The American Illustrated Medical Dictionary. A new and com- 
plete dictionary of the terms used in Medicine, Surgery, Dentistry, 
Pharmacy, Chemistry, and kindred branches; with over 100 new and 
elaborate tables and many handsome illustrations. By W. A. Newman 
Dorland, M. D., Editor of "The American Pocket Medical Diction- 
ary." Large octavo, nearly 850 pages, bound in full flexible leather. 
Price, $4.50 net; with thumb index, $5.00 net. 

Gives a Maximum Amount of Matter in a Minimum Space, and at the Lowest 

Possible Cost 
WITH 2000 NEW TERMS 

The immediate success of this work is due to the special features that distin- 
guish it from other books of its kind. It gives a maximum of matter in a mini- 
mum space and at the lowest possible cost. Though it is practically unabridged, 
yet by the use of thin bible paper and flexible morocco binding it is only 1 % 
inches thick. The result is a truly luxurious specimen of book-making. In this 
new edition the book has been thoroughly revised, and upward of two thousand 
new terms that have appeared in recent medical literature have been added, thus, 
bringing the book absolutely up to date. The book contains hundreds of terms 
not to be found in any other dictionary, over 100 original tables, and many hand- 
some illustrations, a number in colors. 



PERSONAL OPINIONS 



Howard A. Kelly, M. D., 

Professor of Gynecology , Johns Hopkins University , Baltimore. 

" Dr. Dorland's dictionary is admirable. It is so well gotten up and of such convenient 
size. No errors have been found in my use of it." 

J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.) 

Professor of Surgery, Harvard Medical School. 

"I regard it as a valuable aid to my medical literary work. It is very complete and of 
convenient size to handle comfortably. I use it in preference to any other." 



EMBRYOLOGY. 



Heisler's 
Text-Book qf Embryology 

Recently Issued— The New (3d) Edition 



A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
Octavo volume of 435 pages, with 212 illustrations, 32 of them in 
colors. Cloth, $3.00 net. 

WITH 212 ILLUSTRATIONS, 32 IN COLORS 

The fact of embryology having acquired in recent years such great interest 
in connection with the teaching and with the proper comprehension of human 
anatomy, it is of first importance to the student of medicine that a concise and 
yet sufficiently full text-book upon the subject be available. This new edition 
represents all the latest advances recently made in the science of embryology. 
Many portions have been entirely rewritten, and a great deal of new and impor- 
tant matter added. A number of new illustrations have also been introduced and 
these will prove very valuable. The previous editions of this work filled a gap 
most admirably, and this new edition will undoubtedly maintain the reputation 
already won. Heisler's Embryology has become a standard work. 



PERSONAL AND PRESS OPINIONS 



G. Carl Huber, M. D., 

Professor of Histology and Embryology ; University of Michigan, Ann Arbor. 
" I find the second edition of ' A Text-Book of Embryology' by Dr. Heisler an improve- 
ment on the first. The figures added increase greatly the value of the work. I am again 
recommending it to our students." 

William Wathen, M. D., 

Professor of Obstetrics, Abdominal Surgery, and Gynecology, and Dean, Kentucky School of 

Medicine, Louisville, Ky. 
" It is systematic, scientific, full of simplicity, and just such a work as a medical student 
will be able to comprehend." » 

Birmingham Medical Review, England 

" We can most confidently recommend Dr. Heisler's book to the student of biology or 
medicine for his careful study, if his aim be to acquire a sound and practical acquaintance with 
the subject of embryology." 



SAUNDERS' BOOKS ON 



Mallory and Wright's 
Pathologic Technique 

Recently Issued— Third Edition, Revised and Enlarged 



Pathologic Technique. A Practical Manual for Workers in Patho- 
logic Histology, including Directions for the Performance of Autopsies 
and for Clinical Diagnosis by Laboratory Methods. By Frank B. 
Mallory, M. D., Associate Professor of Pathology, Harvard Univer- 
sity ; and James H. Wright, M. D., Director of the Clinico-Pathologic 
Laboratories, Massachusetts General Hospital. Octavo of 469 pages, 
with 138 illustrations. Cloth, $3.00 net. 

WITH CHAPTERS ON POST-MORTEM TECHNIQUE AND AUTOPSIES 

In revising the book for the new edition the authors have kept in view the 
needs of the laboratory worker, whether student, practitioner, or pathologist, for 
a practical manual of histologic and bacteriologic methods in the study of patho- 
logic material. Many parts have been rewritten, many new methods have been 
added, and the number of illustrations has been considerably increased. Among 
the many changes and additions may be mentioned the amplification of the de- 
scription of the Parasite of Actinomycosis and the insertion of descriptions of the 
Bacillus of Bubonic Plague, of the Parasite of Mycetoma, and Wright's methods 
for the cultivation of Anaerobic Bacteria. There have also been added new 
staining methods for elastic tissue by Weigert, for bone by Schmorl, and for con- 
nective tissue by Mallory. The new edition of this valuable work keeps pace 
with the great advances made in pathology, and will continue to be a most useful 
laboratory and post-mortem guide, full of practical information. 



PERSONAL AND PRESS OPINIONS 



Wm. H. Welch, M. D., 

Professor of Pathology, Johns Hopkins University, Baltimore. 

" I have been looking forward to the publication of this book, and I am glad to say that I 
find it a most useful laboratory and post-mortem guide, full of practical information and well 
up to date." 

Boston Medical and Surgical Journal 

" This manual, since its first appearance, has been recognized as the standard guide in patho- 
logical technique, and has become well-nigh indispensable to the laboratory worker." 

Journal of the American Medical Association 

" One of the most complete works on the subject, and one which should be in the library 
of every physician who hopes to keep pace with the great advances made in pathology." 



HISTOLOGY. 



Bohm, Davidoff, and 
Huber's Histology 



A Text=Book of Human Histology. Including Microscopic Tech- 
nic. By Dr. A. A. Bohm and Dr. M. von Davidoff, of Munich, and 
G. Garl Huber, M. D., Professor of Histology and Embryology in 
the University, of Michigan, Ann Arbor. Handsome octavo of 528 
pages, with 361 beautiful original illustrations. Flexible cloth, $3.50 net. 

RECENTLY ISSUED— NEW (2d) EDITION, ENLARGED 

The work of Drs. Bohm and Davidoff is well known in the German edition, 
and has been considered one of the most practically useful books on the subject 
of Human Histology. This second edition has been in great part rewritten and 
very much enlarged by Dr. Huber, who has also added over one hundred origi- 
nal illustrations. Dr. Huber's extensive additions have rendered the work the 
most complete students' text-book on Histology in existence. 

Boston Medical and Surgical Journal 

" Is unquestionably a text-book of the first rank, having been carefully written by thorough 
masters of the subject, and in certain directions it is much superior to any other histological 
manual." 



DrewV 

Invertebrate Zoology 

A Laboratory Manual of Invertebrate Zoology. By Gilman A. 
Drew, Ph.D., Professor of Biology at the University of Maine. With the 
aid of Members of the Zoological Staff of Instructors of the Marine Biolog- 
ical Laboratory, Woods Holl, Mass. i2mo of 200 pages. Cloth, $1.25 net. 

RECENTLY ISSUED 

The subject is presented in a logical way, and the type method of study has 
been followed, as this method has been the prevailing one for many years. 

Prof. Allison A. Smyth, Jr., Virginia Polytechnic Institute 

" I think it is the best laboratory manual of zoology I have yet seen. The large number 
of forms dealt with makes the work applicable to almost any locality." 



io SAUNDERS' BOOKS ON 



McFarland's 
Pathogenic Bacteria 

The New (5th) Edition, Revised 



A Text>Book Upon the Pathogenic Bacteria. By Joseph McFar- 
land, M. D., Professor of Pathology and Bacteriology in the Medico- 
Chirurgical College of Philadelphia, Pathologist to the Medico-Chirur- 
gical Hospital, Philadelphia, etc. Octavo volume of 647 pages, finely 
illustrated. Cloth, $3.50 net. 

RECENTLY ISSUED 

This book gives a concise account of the technical procedures necessary in the 
study of bacteriology, a brief description of the life-history of the important patho- 
genic bacteria, and sufficient description of the pathologic lesions accompanying 
the micro-organismal invasions to give an idea of the origin of symptoms and the 
causes of death. The illustrations are mainly reproductions of tr e best the world 
affords, and are beautifully executed. In this edition the entire work has been 
practically rewritten, old matter eliminated, and much new matter inserted. 

H. B. Anderson, M. D., 

Professor of Pathology and Bacteriology, Trinity Medical College, Toronto. 
" The book is a satisfactory one, and I shall take pleasure in recommending it to the students 
of Trinity College." 

The Lancet, London 

" It is excellently adapted for the medical students and practitioners for whom it is avowedly 
written. . . . The descriptions given are accurate and readable." 



Hill's Histology and Organography 

A Manual of Histology and Organography. By Charles Hill, 
M. D., Professor of Histology and Embryology, Northwestern Univer- 
sity, Chicago. i2mo of 463 pages, 313 illustrations. Flexible leather, 
£2.00 net. 

RECENTLY ISSUED 

Dr. Hill's fifteen years' experience as a teacher of histology has enabled him to 
present a work characterized by clearness and brevity of style and a completeness 
of discussion rarely met in a book of its pretensions. Particular consideration is 
given the mouth and teeth ; and illustrations are most freely used. 



BA CTERIOLOG Y AND PA THOLOG Y. 



Eyre's 
Bacteriologic Technique 



The Elements of Bacteriologic Technique. A Laboratory Guide 
for the Medical, Dental, and Technical Student. By J. W. H. Eyre, 
M.D., F. R. S. Edin., Bacteriologist to Guy's Hospital, London, and 
Lecturer on Bacteriology at the Medical and Dental Schools, etc. 
Octavo volume of 375 pages, with 170 illustrations. Cloth, $2.50 net. 

FOR MEDICAL, DENTAL, AND TECHNICAL STUDENTS 

This book presents, concisely yet clearly, the various methods at present in 
use for the study of bacteria, and elucidates such points in their life-histories as 
are debatable or still undetermined. It includes only those methods that are 
capable of giving satisfactory results even in the hands of beginners. The illus- 
trations are numerous and practical. The work is designed with the needs of the 
technical student generally constantly in view. 

The Lancet, London 

" Stamped throughout with evidence that the writer is a practical teacher, and the directions 
are more clearly given . . . than in any previous work." 

Warren's 

Pathology and Therapeutics 

Surgical Pathology and Therapeutics. By John Collins Warren, 
M. D., LL.D., F.'R. C. S. (Hon.), Professor of Surgery, Harvard Medical 
School. Octavo, 873 pages, 136 relief and lithographic illustrations, 33 
in colors. With an Appendix on Scientific Aids to Surgical Diagnosis 
and a series of articles on Regional Bacteriology. Cloth, $5.00 net; 
Sheep or Half Morocco, $6.50 net. 

SECOND EDITION, WITH AN APPENDIX 

In the second edition of this book all the important changes have been em- 
bodied in a new Appendix. In addition to an enumeration of the scientific aids to 
surgical diagnosis there is presented a series of sections on regional bacteriology, 
in which are given a description of the flora of the affected part, and the general 
principles of treating the affections they produce. 

Roswell Park, M. D., 

In the Harvard Graduate Magazine. 

" I think it is the most creditable book on surgical pathology, and the most beautiful medical 
illustration of the bookmakers' art that has ever been issued from the American press." 



12 SAUNDERS' BOOKS ON 

Dtirck and Hektoen's 

Special Pathologic Histology 

Atlas and Epitome of Special Pathologic Histology. By Dr. H. 

Durck, of Munich. Edited, with additions, by Ludvig Hektoen, M. D., 
Professor of Pathology, Rush Medical College, Chicago. In two parts. 
Part I. — Circulatory, Respiratory, and Gastro-intestinal Tracts. 120 
colored figures on 62 plates, and 158 pages of text. Part II. — Liver, 
Urinary and Sexual Organs, Nervous System, Skin, Muscles, and 
Bones. 123 colored figures on 60 plates, and 192 pages of text. Per 
part : Cloth, $3.00 net. In Saunders' Hand- Atlas Series. 

The great value of these plates is that they represent in the exact colors the effect 
of the stains, which is of such great importance for the differentiation of tissue. 
The text portion of the book is admirable, and, while brief, it is entirely satisfac- 
tory in that the leading facts are stated, and so stated that the reader feels he has 
grasped the subject extensively. 

William H. Welch, M. D., 

Professor of Pathology, Johns Hopkins University, Baltimore. 

"I consider Durck's 'Atlas of Special Pathologic Histology,' edited by Hektoen, a very 
useful book for students and others. The plates are admirable." 

Sobotta and Huber's 
Human Histology 

Atlas and Epitome of Human Histology. By Privatdocent Dr. 
J. Sobotta, of Wiirzburg. Edited, with additions, by G. Carl Huber, 
M. D., Professor of Histology and Embryology in the University of 
Michigan, Ann Arbor. With 214 colored figures on 80 plates, 68 
text-illustrations, and 248 pages of text. Cloth, $4.50 net. In 
Saunders' 1 Hand- Atlas Series. 

INCLUDING MICROSCOPIC ANATOMY 

The work combines an abundance of well-chosen and most accurate illustra- 
tions, with a concise text, and in such a manner as to make it both atlas and text- 
book. The great majority of the illustrations were made from sections prepared 
from human tissues, and always from fresh and in every respect normal specimens. 
The colored lithographic plates have been produced with the aid of over thirty colors. 

Boston Medical and Surgical Journal 

"In color and proportion they are characterized by gratifying accuracy and lithographic 
beauty." 



PHYSIOLOGY. 13 



American Text- Book of Physiology 



American Text=Book of Physiology. In two volumes. Edited by 
William H. Howell, Ph.D., M. D., Professor of Physiology in the 
Johns Hopkins University, Baltimore, Md. Two royal octavo volumes 
of about 600 pages each, fully illustrated. Per volume : Cloth, $3.00 
net ; Sheep or Half Morocco, $4.25 net. 

SECOND EDITION, REVISED AND ENLARGED 

Even in the short time that has elapsed since the first edition of this work 
there has been much progress in Physiology, and in this edition the book has been 
thoroughly revised to keep pace with this progress. The chapter upon the Cen- 
tral Nervous System has been entirely rewritten. A section on Physical Chem- 
istry forms a valuable addition, since these views are taking a large part in current 
discussion in physiologic and medical literature. 

The Medical News 

" The work will stand as a work of reference on physiology. To him who desires to know 
the status of modern physiology, who expects to obtain suggestions as to further physiologic 
inquiry, we know of none in English which so eminently meets such a demand." 

Stewart's Physiology 



A Manual of Physiology, with Practical Exercises. For Students 
and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, Professor 
of Physiology in the University of Chicago, Chicago. Octavo 
volume of 911 pages, with 395 text-illustrations and colored plates. 

Cloth, $4.00 net. 

RECENTLY ISSUED— NEW (5th) EDITION 



This work is written in a plain and attractive style that renders it particularly 
suited to the needs of students. The systematic portion is so treated that it can 
be used independently of the practical exercises. In the present edition a con- 
siderable amount of new matter has been added, especially to the chapters on 
Blood, Digestion, and the Central Nervous System. 

Philadelphia Medical Journal 

" Those familiar with the attainments of Prof. Stewart as an original investigator, as a 
teacher and a writer, need no assurance that in this volume he has presented in a terse, concise, 
accurate manner the essential and best established facts of physiology in a most attractive 
manner." 



i 4 SAUNDERS' BOOKS ON 

Levy and Klemperer's 
Clinical Bacteriology 

The Elements of Clinical Bacteriology. By Drs. Ernst Levy and 
Felix Klemperer, of the University of Strasburg. Translated and 
edited by Augustus A. Eshner, M. D., Professor of Clinical Medicine, 
Philadelphia Polyclinic. Octavo volume of 440 pages, fully illustrated. 
Cloth, $2.50 net. 

S. Solis-Cohen, M. D., 

Professor of Clinical Medicine, Jefferson Medical College, Philadelphia. 
" I consider it an excellent book. I have recommended it in speaking to my students." 

Lehmann, Neumann, and 
Weaver's Bacteriology 

Atlas and Epitome of Bacteriology : including a Text-Book of 
Special Bacteriologic Diagnosis. By Prof. Dr. K. B. Lehmann 
and Dr. R. O. Neumann, of Wiirzburg. From the Second Revised and 
Enlarged German Edition. Edited, with additions, by G. H. Weaver, 
M. D., Assistant Professor of Pathology and Bacteriology, Rush Medical 
College, Chicago. In two parts. Part I. — 632 colored figures on 69 
lithographic plates. Part II. — 511 pages of text, illustrated. Per part: 
Cloth, $2.50 net. In Saunders' Hand- Atlas Series. 

Lewis' Anatomy and Physi- 
ology for Nurses 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., 
Surgeon to and Lecturer on Anatomy and Physiology for Nurses at 
the Lewis Hospital, Bay City, Michigan. i2mo of 317 pages, with 
146 illustrations. Cloth, $1.75 net. 

RECENTLY ISSUED 

Nurses Journal of the Pacific Coast 

" It is not in any sense rudimentary, but comprehensive in its treatment of the subjects in 



hand." 



PATHOLOGY, BACTERIOLOGY, AND PHYSIOLOGY. 15 

Seiin'S TtimOrS Second Revised Edition 

Pathology and Surgical Treatment of Tumors. By Nicholas 
Senn, M. D., Ph. D., LL.D., Professor of Surgery, Rush Medical Col- 
lege, Chicago. Handsome octavo, 718 pages, with 478 engravings, 
including 12 full-page colored plates. Cloth, $5.00 net; Sheep or Half 
Morocco, $6. 50. net. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our 
language for some years."— Journal of the American Medical Association. 

Stoney's Bacteriology and Technic £ffi%£L 

Bacteriology and Surgical Technic for Nurses. By Emily M. A. 
Stoney, Superintendent, Carney Hospital, Mass. Revised by Frederic 
R., Griffith, M.D., Surgeon, N. Y. i2mo of 278 pages, illustrated. 
$1.50 net. 

"These subjects are treated most accurately and up to date, without the superfluous 
reading which is so often employed. . . . Nurses will find this book of the greatest value." 
— The Trained Nurse and Hospital Review. 

Clarkson's Histology 

A Text-Book of Histology. Descriptive and Practical. For the 
Use of Students. By Arthur Clarkson, M. B., C. M. Edin., formerly 
Demonstrator of Physiology in the Owen's College, Manchester, Eng- 
land. Octavo, 554 pages, with 174 colored original illustrations. 
Cloth, $4.00 net. 

" The volume in the hands of students will greatly aid in the comprehension of a sub- 
ject which in most instances is found rather difficult. . . . The work must be considered 
a valuable addition to the list of available text-books, and is to be highly recommended." 
— New York Medical Journal. 

Gorham's Bacteriology 

A Laboratory Course in Bacteriology. For the Use of Medical, 
Agricultural, and Industrial Students. By Frederic P. Gorham, A. M., 
Associate Professor of Biology in Brown University, Providence, R. I., 
etc. i2mo of 192 pages, with 97 illustrations. Cloth, $1.25 net. 

" One of the best students' laboratory guides to the study of bacteriology on the mar- 
ket. . . . The technic is thoroughly modern and amply sufficient for all practical pur- 
poses." — American Journal of the Medical Sciences. 

Raymond's Physiology £%%£& 

Human Physiology. By Joseph H. Raymond, A. M., M. D., Pro- 
fessor of Physiology and Hygiene, Long Island College Hospital, New 
York. Octavo of 685 pages, with 444 illustrations. Cloth, $3.50 net. 

" The book is well gotten up and well printed, and may be regarded as a trustworthy 
guide for the student and a useful work of reference for the general practitioner. The 
illustrations are numerous and are well executed." — The Lancet, London. 



16 BACTERIOLOGY, PHYSIOLOGY, AND HISTOLOGY. 

Ball's Bacteriology Recently Issued-Fifth Edition, Revised 

Essentials of Bacteriology : being a concise and systematic intro- 
duction to the Study of Micro-organisms. By M. \. Ball, M. D., Late 
Bacteriologist to St. Agnes' Hospital, Philadelphia. i2mo of 236 pages, 
with 96 illustrations, some in colors, and 5 plates. Cloth, #1.00 net. In 
Saunders'' Question- Compend Series. 

" The technic with regard to media, staining, mounting, and the like is culled from the 
latest authoritative works." — The Medical Times, New York. 

n 1 . a m • rki • 1 , Recently Issued 

BudgettS PhySlOlOgy New (2d) Edition 

Essentials of Physiology. Prepared especially for Students of Medi- 
cine, and arranged with questions following each chapter. By Sidney 
P. Budgett, M. D., Professor of Physiology, Medical Department of 
Washington University, St. Louis. i6mo volume of 233 pages, finely 
.illustrated with many full-page half-tones. Cloth, #1.00 net. In 
Saunders' Question- Compend Series. 

"He has an excellent conception of his subject. . . It is one of the most satisfactory 
books of this class" — University of Pennsylvania Medical Bulletin. 
w t w A 1 -^ Recently Issued 

Leroy s Histology New (3d) Edition 

Essentials of Histology. By Louis Leroy, M. D., Professor of 

Histology and Pathology, Vanderbilt University, Nashville, Tennessee. 

i2mo, 263 pages, with 92 original illustrations. Cloth, $1.00 net. In 

Saunders' Question- Compend Series. 

" The work in its present form stands as a model of what a student's aid should be ; and 
we unhesitatingly say that the practitioner as well would find a glance through the book 
of lasting benefit." — The Medical World, Philadelphia. 

Bastin's Botany 

Laboratory Exercises in Botany. By the late Edson S. Bastin, 
M. A. Octavo, 536 pages, with 87 plates. Cloth, $2.00 net. 

Barton and Wells' Medical Thesaurus 

A Thesaurus of Medical Words and Phrases. By Wilfred M. 
Barton, M. D., Assistant Professor of Materia Medica and Therapeutics, 
and Walter A. Wells, M.D., Demonstrator of Laryngology, Georgetown 
University, Washington, D. C. i2mo, 534 pages. Flexible leather, 
$2.50 net; thumb indexed, $3.00 net. 
- „ ■»«'..«*•,• Fifth Revised Edition 

American Pocket Dictionary Recently issued 

Dorland's Pocket Medical Dictionary. Edited by W. A. New- 
man Dorland, M. D., Assistant Obstetrician to the Hospital of the 
University of Pennsylvania. Containing the pronunciation and defini- 
tion of the principal words used in medicine and kindred sciences, with 
64 extensive tables. Handsomely bound in flexible leather, with gold 
edges, $1.00 net; with patent thumb index, $1.25 net. 

" I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., 
of the Jefferson Medical College, Philadelphia. 



JUL 8 1908 



LIBRARY OF CONGRESS 



022 216 104 6 



